I need all of your thoughts on this...

[FunnyDuddies 6]

ok...so I started at Nordstrom yesterday. And they have Aetna PPO insurance. The HR manager is checking to see if they allow bariatric surgery. If they do...I am a shoe in. way over BMI of 40. Way over the 100 pounds over weight. A few comorbidities. No problem.

Dh's insurance is United Healthcare. Great right? No. All of their new policies they are sneaking in an exclusionary clause for no bariatric or nutrition coverage. So we are not covered.

So we have chosen to get my surgery with Dr. Sanchez in monterrey Mx. But now there is the possiblity that it will be covered.

Dr. Sanchez is an amazing doctor. He has done a lot of lap bands. (over 5k) And the hospital is a great american owned hospital in one of the most beauiful cities in Mexico.

What do I do? If I go with the insurance I can't even start the process until july 1st. There is a waiting period before the insurance kicks in. Do I go for the insurance covered surgery, wait the extra time? Is there anything I should do until then to help make the process go quickly after the insurance kicks in?

Or do I go with the years of exp and the many many lap bands under his belt, and the amazing hospital in the amazing city in mx?

To some this may be a no brainer on either side, but I am really stuck trying to figure this out. Thanks in advance.

[MyKdsDad 1]

My first question is, do you have the cash-o-lah to self pay, right now? I believe the first thing I would do (if you don't) is start saving toward that end. And if the insurance kicks in before you have the money, apply with it. If not, Viva Mexico!

[Alexandra 55]

IMO there are several very strong reasons to get insurance to cover it locally if you can. Financial reasons, of course, take a higher or lower place on your list, but if you do have insurance cover your surgery then you'll also be covered down the line for adjustments or complications. That may or may not be important to you, but it sure was for me.

Access to medical followup is probably the biggest plus to having it done locally. Even if money is not an object, U.S. doctors simply may not want to treat someone with a band installed in Mexico. I think this could set someone up for serious trouble down the road in unexpected ways.

Getting Aetna to cover my banding wasn't easy--it took months of appeals but I finally prevailed. If your big-company policy covers it you'll be way better off than I was. Waiting until July to have it done seems (to me) a very small price to pay compared to shelling out thousands of dollars now and investing untold amounts of future money and time to have surgery in another country.

[FunnyDuddies 6]

i have the money. at least most of it. I am $500 short, but that is no biggie. I'll have that in the next check. My mx date is for April 28 due to my schedule. If I do not go with that and go with insurance I am going to be saving a total of 11k due to other things I have to pay for and etc.

[HeatherGurl 0]

Why don't you wait until you know for SURE if you are going to be covered by your insurance or not? Then I would make a decision.

I would much rather choose to have it done closer to home because after care is just as important as surgery.... So, unless you live in Mexico??? I would personally just see what insurance is going to do...

GOOD LUCK WITH IT!!!

[JanetC 2]

If there's ANY way you can make yourself wait, I'd see if insurance will cover it. Why?

1. Follow-up care. American doctors often do not want to take patients from Mexico for whatever reason. If they DO take you, they charge you through the nose.

2. Emergency follow-up care. If you do have issues, you have to fly to Mexico. If it's a case of not being able to swallow... can you stand the time in a plane? Folks have found nice people in ER's that will call Mexico & allow themselves to be talked through an un-fill. It just all sounds scary & iffy to me.

3. Paying for follow-up long term. If the surgery wasn't covered, any follow-up most likely won't be covered. Issues probably will be pre-existing or not covered. So you're not just looking at 10k now, but 10k per revision & 100 per fill, etc.

Yeah, I painted a worse case scenario. I'm self-pay as well & terrified that we may someday need a 2nd surgery. We've started saving for that "just in case". But if it does happen, I already know my surgeon... and my hospital. They're just down the road. :welldone2:

We're self-employed & that's unlikely to change. If I'd had any possibility of having better insurance soon, I'd have waited (screaming, groaning & complaining... but waiting).

Sorry to be a downer & remember it's just my opinion. :scared: Go with your gut!!

[FunnyDuddies 6]

Alex...can you clarify for me your issues with aetna? Did you have to appeal because your company did not cover it? I am just curious. Is aetna just that hard to deaal with? Or is it that you had to jump some hurdles your company put up to try to keep people from getting the surgery, like dh's company.

[donali 57]

I was self-pay, and had an additional 7-$8,000 in expenses after my banding - a port revision, fills, and my unbanding.

I would go the insurance route, if at all possible. Aftercare is a must, and unless Monterrey is very convenient to you, you may put off necessary care due to expense or time required to travel.

You could be one of the lucky ones that never has any additional expenses, or you could be like Deb who was out an additional $70,000 with an impacted bowel, numerous abdominal abcesses, peritonities and 90% eroded band.

Unlikely, but insurance is a great thing in that case! :welldone2:

I know how hard it is to wait - I really do.

[FunnyDuddies 6]

Thanks guys. All of those points are well taken.

Donali, I agree that insurance is a GREAT thing. I really do love the idea of being covered.

it is just so hard to walk away from the expertise and care that people have received from Dr. Sanchez.

This is a hard decision. Any more thoughts will be very appreciated. I value the opinions of everyone here on this.

[Alexandra 55]

Alex...can you clarify for me your issues with aetna? Did you have to appeal because your company did not cover it? I am just curious. Is aetna just that hard to deaal with? Or is it that you had to jump some hurdles your company put up to try to keep people from getting the surgery, like dh's company.

I was denied by Aetna back in 2002 because at that time they still considered the band experimental. It took 9 months of appeals and finally a third-party review to have that decision overturned.

Aetna no longer considers the band experimental, but they still prefer RNY over banding as a surgical treatment for morbid obesity. However, that's a lot easier to fight than a total exclusion.

Your policy is likely a large-group plan where it's the group that calls the shots about what's covered and what isn't, so if your HR person comes back to you with good news that's all that matters. Good luck!!

[FunnyDuddies 6]

Thank you alex. I appreciate the info. That is good to know.

Any of you out there who got approved with aetna, what hoops did they make you jump through? What can I start working on now?

[the best me 6]

If I could have this covered under insurance and stay in the states, you bet I would. And I like my MX doc and the experience he has! I was also ready to get going and didn't want to do all the hoop jumping. But I had no hope of coverage, so it realy wasn't a decision I had to make based on that.

That's a tough one, but if I had to be honest, stateside WITH insurance, or MX without, I'd stay in the good ole US.

Now, banded by a great doc in MX and coming home to covered fills and aftercare is like dreamland...what I wouldn't give! Sorry, I guess I'm not that helpful. :welldone2:

[Chris S. - L.I. 0]

I think everyone already said what I was going to say. Wait for the insurance so you will be covered for the surgery, aftercare and any unforseen circumstances.

Chris S.

[CCBSTX 0]

Good luck with your decision! Maybe insurance will cover and pay. Then you can use the money to go on a vacation to Mexico!

Shawn

[ReneBean 3]

*I will say that you may still have to fight the insurance company - if you have a high BMI like me. I started at 59 - and Blue Cross said I had to get By-Passed or Switched. Since I wasn't having any of that, I fought - for four months - before I got my surgery.

If you do decide to battle for insurance - be aware that it MIGHT take some time - maybe lots. However, for the follow-up care and any potential complications, I would still fight for it - no matter how long it takes.

Just my opinion.