need advice- what would you do?

MikeC · March 9, 2005

Okay, this is my situation.... I went to see a US bariatric surgeon for a consultation a few months ago to see about getting banded. Her insurance lady told me that my carrier (Cigna POS) specifically excluded the lap band. This made sense to me because I have read that Cigna does not cover the band on this site as well as other boards. I didn’t bother calling the company or my PCP figuring I’d only get annoyed. I threw my energy into researching the lap band and Mexican surgeons and decided on Dr. Ortiz in TJ. I filled out my health questionnaire, scheduled the surgery and paid the surgical fee. I’m scheduled to be banded in less than two weeks.

Today I called Cigna to make sure that if God forbid something serious goes wrong after the surgery while I’m back in NY, that they will cover emergency medical expenses- even if caused by non covered surgery. Well the lady told me that not only would I be covered, but that weight loss surgery (including the band) is covered under my policy as long as it is medically necessary and approved in advance. Now what do I do? Should I cancel my Mexican surgery and jump through the hoops to have my surgery paid for in the US or just say the heck with it and get it done in Mexico and be done with it all in two weeks. Going by other people’s experiences, I wouldn’t be surprised if the entire process takes 9 months for surgery and insurance approvals in the US. I don’t want to wait that long, especially after getting my self all mentally prepared for surgery in two weeks (not to mention losing the 20lbs the doctor requested). Other than being MO, I have no other medical problems so I feel it will be a long process for the insurance to go through. Then again, $9,500 is a lot of money and it would be comforting having the surgery done close to home.

I'm leaning towards going through with the surgery in Mexico as planned; but I hate feeling that I’m not exercising self restraint-- especially when I feel lack of self restrain is the reason I’ve stayed fat all these years.

Penni60 · March 9, 2005

Mike: If I were in your shoes, I would have the surgery. But let me put this bug in your ear, did you realize you can apply for reimbursement from your insurance company after the surgery? There of course is no guarantee that they will reimburse but it is possible.

I had the surgery in MX. I am in the process now of the filing for reimbursement. It is a long drawn out battle but it is looking hopeful I will get some of my money back. And just think I have lost 56 lbs in the process.

But I think you have already answered your own question. Good luck.

taylorrae9 · March 9, 2005

Mike,

You doen't say where you are from but I had a much shorter waiting period in SF Laproscopic Associates. You might call and see what the wait will be before making the chose.

Good luck.

Melanie

New Hope · March 9, 2005

Well, Mike, only you can make the final decision. If you don't have any co-morbidities, it's doubtful your insurance company will approve you. And there is the possibility of having to wait while you jump through all their hoops. But if you think you have a chance, then perhaps you could check w/a local band dr. (covered by your ins. co.) and get some facts. It would definitely save you $$ and be more convenient if it was doable.

If you go to Mexico, you've chosen a good band dr. w/ a solid reputation. Do you have your aftercare lined up? A local band dr. in the event of an emergency (that you've double-checked about accepting you) or for fills? If you're returning to Mexico for your fills, are you budgeting for the trip...time off work, hotel, food, travel, fill costs (if any).

There's a lot to think about. Best of luck to you! Please let us know what you decide.

P. S. Did you ever find out about "taking a punch" to the port area?

the best me · March 9, 2005

I'm leaning towards going through with the surgery in Mexico as planned; but I hate feeling that I’m not exercising self restraint-- especially when I feel lack of self restrain is the reason I’ve stayed fat all these years.

Very observant...Oh man, I don't know what I'd do!!! I would start pursuing the insurance route, but not cancel MX until you get a feel for how long it will take. Or postpone MX for 1 month, and see where your insurance takes you.

O, blast it all, go to MX and hope for reimbursement.

Well, now your back to square one...Good luck and let us know what you decide!

March 9, 2005

Hello, I'm A New Member And I Too Was Thinking Of Lap Band, But I Have A Question How Does Insurance Company Work If U Are Approved Do U Have To Pay The Insurance Company Back The Money Monthly, My Question Sounds Dumb But Nothing Is For Free, And Another Question Does Anyone Has/had United Health Insurance: Thanks Betty

Alexandra · March 9, 2005

MikeC, I'm with Jack. Getting surgery locally was more important to me than getting it fast. I fought with my insurer for almost a year and eventually won. It's been worth it in spades because my doctor is 15 minutes away and I've gotten the excellent care I knew I'd need to be successful.

If you're medically qualified for bariatric surgery, start the process and see what happens. Mexico will always be there for you, if you need it. But if you do manage to get Cigna to pay for it you'll be thousands of dollars ahead and have local coverage with no worries.

And Betty, if you have United Healthcare you'll be happy to hear it's one of the best carriers out there for bariatric surgery. And no, you don't have to pay it back. You or your employer have been paying premiums and what you get in return is coverage for medical care if you need it. And if you need it you'll have to pay whatever copays and deductibles might apply, but you will NOT have to repay whatever portion of the expenses United agrees to cover.

MikeC · March 11, 2005

Well it turns out my Cigna plan (or any cigna plan for that matter) DOES NOT cover the lap band. The idiot woman I spoke with on the phone originally was wrong. I checked and doubled checked to make sure. I even asked the VP of HR at my company to check as well. I also read it in Cigna's coverage position paper for bariatric surgery which was pretty interesting and informative. So phew, I'm so glad that descion has been made for me. I've lined up my aftercare here in NY so that won't be a problem- I just need a letter from my surgon and a copy of his post op notes to fax over after the surgery, although I think I'll just go back to MX for the fills (an excuse for a mini vacation). After the surgery I'll gamble a stamp and file for reimbursement- you never know they may give in especially if pressure my employer (we are self funded).

Thanks to all of you for you advise and support. Oh, and Marie the consensus was that both my port and I would survive the punch! Thanks for asking

La_madam · March 11, 2005

Mike, Best of Luck to you on your upcoming surgery with Dr. Ortiz, he is a wonderful doctor in my opinion. He is very experienced and very caring. Dr. Ortiz and his entire staff will take good care of you and please your every need while in TJ. You are in very good hands

I am an extremely happy Ortiz patient.

princess_n_thep · March 11, 2005

I too have my surgery with Dr. Ortiz in 12 days (woot!) and I am a non insurance covered. Although, my opinion was to heck with all the waiting, red tape, and forms for the US insurance. My only consolation is that with the doctors receipt it is tax deductable even though I didn't get it in the US.

I'llsucceed · March 11, 2005

I'm With Jack & Alex

Boy what a pickle you in.. I can see the frustration. I wanted mine months ago. Than started the hoop jumping knowing that even if there was a slim chance of being covered & going local I want it. The Its only been 3 extra months & I should know VERY soon. Was it worth the wait for me-YES. Its so much less of a worry to have a Local Doctor to go to anytime & to be held accountable & the support groups most supply than to be away from home. Yes! You save a bundle but the after care is so crucial & just think How much more you MAY save if you just wait 90 days & its covered. That will buy a whole new wardrobe or a masive vacation & wardrobe!

But you know in your heart what you need & From those whom have gone before you( to TJ) they are successful.. Best of luck- Let us know what happens!!