New Here And A Few Questions :)

[DrSayrahK 2]

Hello Everyone! I have really enjoyed reading and learning about VSG on this site! Super helpful and encouraging!

I am hoping and planning to have surgery in November, probably the week I am out for Thanksgiving break. This is also my 1st Anniversary, my husband is being such an amazing sport and huge encouragement!

I had hoped to have my insurance cover my surgery at a local hospital, however, since filling out the paperwork I have been told that my insurance won't cover "elective surgeries" without it being medically necessary. 1st question- has anyone been able to prove the surgery was medically necessary? I have PCOS, high blood pressure, and asthma. I can't imagine how those 3 things aren't medically necessary. Any thoughts on this? There aren't really any guidelines for wls with my insurance, so I have no idea how this works.

If I am unable to have the surgery here in the states, I would really like to go to Mexico. Years ago, a lady that helped in my classroom had the lapband surgery in Mexico, I thought she was crazy. After reading up on the surgery and the different doctors there, I don't feel like it's that bad. My husband is fine with it, he tells me if that's what I want to do, he's there with me. My parents aren't 100% sold on the idea yet. I want them to feel comfortable with it. I think the reason they are worried is because when I was 5 (23 years ago) I had a tonsillectomy and while I was on the table my lungs filled up with Fluid and I almost died. I think this was a reaction to the anesthesia. I have had my wisdom teeth taken out and 2 foot surgeries since that time and didn't have any problems. My concern is I don't think this was the same type.... any thoughts on this? Anyone have knowledge about anesthesia?

I had decided and been in contact with Omar at Dr. Kelly's office in Mexico. There are several other doctors there that I feel would do a wonderful job, however, price is a huge factor for me. So with that being said, would anyone share their Dr. Kelly story with me?

One more thing and I'll be quiet for now, Does anyone know of a place in the USA that is cheaper for the surgery without insurance? My doctor told me it would be $16,000.... OUCH! I just can't afford that. I would need for it to be closer to 6,000. I just don't think I'm going to find that here in the USA.

I have an appointment with my PCP on Tuesday. Maybe he will be able to lead me in the right direction but I figured if anyone had any advice to offer, that'd be wonderful!

Sorry to be so wordy and have so many questions! I look forward to getting to know some of you!

Thanks,

Sarah

[NCsleever63 53]

Hi,

Alot of insurance companies do cover wls. Most require something, BMI Of 40 or more or BMI over 35 and have hypertension, sleep apnea, diabetes etc. If you meet their requirements, but they wont cover at your local hospital, perhaps they will cover at another hospital. Most insurance compnaies have websites that you can register at and log in to see what requirements they have. I would definately check out all your available resources in the US before having to go to Mexico.

[chitowngirl 884]

As far as your insurance. 99% of insurances will not cover an elective surgery unless it is medically necessary. The surgeons office will usually submit a preauthorizarion/predetermination request to your insurance to see if it meets medical necessity according to their guidelines. I would first suggest that you call the customer service number on the back of your insurance card. Ask them first if you have coverage for bariatric surgery, if you do then ask what are the requirements. Good luck.

[DrSayrahK 2]

I have already talked to my insurance a couple of times. I have graduate insurance, if that tells anyone something?

It doesn't list anything specifically for bariatric surgery.... that's the problem. Of course, they are also extremely hesitant to say much on the phone. All they said was according to my policy they do not cover elective surgeries. Bariatric surgery is an elective surgery, so unless it is medically necessary they will not cover. I asked, what exactly does it mean to be medically necessary? They lady said, life threatening. In my opinion, high blood pressure, asthma, and PCOS can all be life threatening....but who knows.

I figured I would talk to my doctor on Tuesday and see what he suggests and then call the hospital back. My insurance also said they wouldn't do a precertification. I would HATE to be stuck with a $16,000 medical bill. I definitely don't have the money to cover that.

[traceyinflorida 499]

If you have a local surgeon that you would use if you are able to pay with surgery I would start with them to help you find out about your insurance coverage. Ask them if they have a bariatric coordinator or someone in the office who can help you with pre-approval process. At that point, they should be able to give you a list of requirements by your insurance company to get the proceedure approved. You may be able to call your insurance company yourself (or go online and get this information). Every insurance company is different, but if they will approve based on medical necessity, then they are looking for your BMI to be over 40 with no co-morbidites or over 35 with co-morbidities (high BP, sleep apnea, diabeties, to name a few). Usually they will want a diet history. Mine required six months of supervised adn documented, consecutive diet and exercise program under a nutritionist before approval. They also required a psych evaluation to make sure I could handle life and eating after surgery. So, basically you need to find what hoops your insurance company wants you to jump through and start working on it. In my area, our hospital and surgeons have a bariatric nutrition center with a bariatric coordinator who helped me through all this. Hopefully yours has something in place as well. I found my PCP to be very supportive, but really not very knowlegeable or helpful with the nuts and bolts of the insurance process. (I needed a letter of medical necessity and medical clearance from them, which I ended up writing myself based on a template the bariatric coordinator gave me and giving to them to tweak and sign) The physician said it was so well written that she would keep it as a template for future patients. LOL.

I can't answer any of the questions about Mexico or cheaper surgeries. I've read lots of great things on this forum about people's experiences with Dr. Kelly in Mexico. You should do a search on this forum for posts about this to give to your parents to allay their fears.

Good luck with all and I hope you get insurance approval!

[DrSayrahK 2]

Thanks ladies! I feel so stuck. The surgeon's office I have been in touch with here said they have never seen an insurance policy like mine. I am getting my PhD, so it's graduate student resource insurance. Just one of those "road blocks" I have to deal with. There aren't any specifics written about baractric surgery, etc. The only mention would be the "elective surgeries" but nothing about wls, etc. So there aren't any "rules" in place for the surgery, etc. That's what makes me think they won't cover it.

@tracey, do you have a copy of the letter you made? If so, do you mind sharing it with me? I would like to go into the doctors office on Tuesday and have everything together and ready for him.

Thanks again ladies! I guess it's just a wait and see sort of thing.

[chitowngirl 884]

Do you mean you have health insurance As a student from your school? You can private message me. I work at a hospital and I verify benefits and do authorizations all day, so I can prob help you clarify this.

[cr354 15]

I got a letter from my insurance company that specifically said my WLS was "medically neccisary". I think most insurance companies require such a thing. You can get your docotor to write that it is considered medically neccisary based on the NIH guidelines and standards of care guides. Depending on what states you live in there are probably a local group that could help out. Find your states chapter of 'American Society for Metabolic and Bariatric Surgery' and you can probably get the guidelines they use to define rather it is medically neccisary. Have your docotor send his letter to the insurance company with the guidelines from the NIH and the local chapter of ASMBS and hopefully that will get you on the right track. You can also call your insurance company and ask to speak with a "Nurse caseworker or case reviewer'.

Good Luck. If there is anything more I can do feel free to message me.

CR