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Self pay vs insurance with likely denial



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So I am prediabetic (not on meds) and have mild sleep apnea (don't need a CPAP). I am starting the insurance process with a BMI of 36. I am looking into bypass since I have terrible reflux. I have labs, chest xray etc. all scheduled thru the MD that insurance will cover but they are an hour drive away. So now I am on the fence. I am thinking I will pursue the pretesting thru the MD that insurance covers and knowing that insurance will deny surgery due to no comorbidities that I will switch over to a local surgeon. The coordinator said she doubts it would be covered and I can not gain a pound or would get denied and can only lose 3 pounds or my BMI goes to low and also would get denied. That would be if I even got covered to begin with. She said when I get weighed in a gown the morning of surgery after being on a liquid diet for 2 weeks this would likely happen.

So now after having a glimmer of hope that it would go thru insurance and realizing that is not an option. I am back to feeling like I'm beating myself up that I'm just being lazy etc that I am even considering a major surgery vs diet and exercise. Then I remember that I have been obese since I was 8 with only a 2 year period at an almost normal weight (but still heavy) and that was with going to the gym 3 hours 6 days a week.

I'm just feeling so frustrated. I would never judge anyone else for doing the surgery but I am so hard on myself. I guess I feel selfish that I would risk something happening and my kids not having me around and spending the money. However both of my parents have diabetes, and have had heart attacks so my future health is a concern if I don't do something.

Edited by 2Bsmaller18
misspelled

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I think you owe it to your kids to be healthy. I have lost quite a bit and have a lot more to go. My daughter said to me the other day that she doesn’t remember me being so happy before. I thought this was an odd statement but it’s a true one. I am still overweight but I just feel happy and healthier. I feel hope for the future and I think my family is benefitting from that. Also I feel like I’ll be around longer. I did self pay in Mexico and couldnt be happier. I was so nervous but now I have no regrets. Good luck on your decision.

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I support the option of doing something. Pre diabetic stage can turn rather quickly. Heart conditions can develop without much previous warning. You don't want that. We support you here! Do what you think is best.

Safe Journey!

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I was going to say, you are a prime candidate for BariatricPal MX. They almost have a better track record than we do here in the states anymore. I'm getting my RNY done in Bellevue, WA through Kaiser but I almost think it would've been better, cheaper and less hassle going to Mexico. Kaiser is dragging this out into the next enrollment year for me which means my deductible will reset. 😏

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1 hour ago, 2Bsmaller18 said:

So I am prediabetic (not on meds) and have mild sleep apnea (don't need a CPAP). I am starting the insurance process with a BMI of 36. I am looking into bypass since I have terrible reflux. I have labs, chest xray etc. all scheduled thru the MD that insurance will cover but they are an hour drive away. So now I am on the fence. I am thinking I will pursue the pretesting thru the MD that insurance covers and knowing that insurance will deny surgery due to no comorbidities that I will switch over to a local surgeon. The coordinator said she doubts it would be covered and I can not gain a pound or would get denied and can only lose 3 pounds or my BMI goes to low and also would get denied. That would be if I even got covered to begin with. She said when I get weighed in a gown the morning of surgery after being on a liquid diet for 2 weeks this would likely happen.

So now after having a glimmer of hope that it would go thru insurance and realizing that is not an option. I am back to feeling like I'm beating myself up that I'm just being lazy etc that I am even considering a major surgery vs diet and exercise. Then I remember that I have been obese since I was 8 with only a 2 year period at an almost normal weight (but still heavy) and that was with going to the gym 3 hours 6 days a week.

I'm just feeling so frustrated. I would never judge anyone else for doing the surgery but I am so hard on myself. I guess I feel selfish that I would risk something happening and my kids not having me around and spending the money. However both of my parents have diabetes, and have had heart attacks so my future health is a concern if I don't do something.

Treatments or not, if those conditions are listed on your charts, and are listed when your doctor submits for approval, those are absolutely co-morbidities. The thing with insurance is, you don't know unless you try. Someone making statements without putting the paperwork through are only guessing. And even then, if you *DO* happen to get denied, you are allowed to appeal. It's all in how the paperwork is processed. If they don't bother to list Pre-diabetic and sleep Apnea... then sure... but they *SHOULD* be putting that into the request for authorization.

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