Decisions, decisions

[Hitorikiri 0]

So I've decided that I definitely want to go ahead with surgery. However, now I have a few decisions facing me and I could use some input.

I have Aetna and they will supposedly cover my surgery 100% as long as I meet the criteria. The problem is, I'm worried I'll get denied because I don't have the adequate weight history, which means I would have to put off the surgery until the summer of next year.

The problem with that is that I'm a temp and don't know if I'll even have the same insurance by that time. In which case I waited for nothing. :svengo:

What I could do instead is apply for financing and get the surgery done in Mexico. In which case I would try to get it done sometime before Christmas or just after New Year's.

What I'm having trouble deciding is if it's better to go through the three month hoop jumping to see if I can get approved with my current weight history at the risk of getting denied, just put it off altogether and hope I have the same insurance next summer, or proceed with trying to get it done in Mexico, and even there should I try for December/January (when I'll have a break from school) or use it as a last resort if next summer doesn't pan out.

I think what I'm having most difficulty is with the idea of waiting nearly another year when I've already made up my mind. I kind of want to just get it over with, you know? But maybe waiting that long would actually be a good thing as it would give me tons of time to prepare.

Basically, I'm conflicted and can use some advice. I'd like to know what would you do in this situation. :confused1: Any feedback you could offer would be most appreciated.

[Donna T 0]

Congrats on your decision! I think I would at least try to get your insurance to pay for it, the worst that could happen is that you would then have to go private pay if it fell through- my insurance specifically excluded any type of bariatric surgery, so I had to pay out of pocket. I am 6 days out now, and starting to feel better and so happy I went ahead with it! Good luck with whichever way you decide to go!

[Jolanda 23]

I was self-pay (I'm in Europe, and the total was around the $15 000 mark) and I've never regretted it one moment. I calculated that I will probably get it back in lower food costs in less than ten years, not to mention the health benefits and quality of life benefits. That said, I understand it's not an option everybody has. But this surgery has done so much to improve my life that I'd never put it off for one month more than necessary if I had to make the choice now.

[TwoStepsBack 15]

Hey gamer buddy,

I too found that once I had made the decision, I didn't want to wait any longer than absolutely necessary. Having said that, it is a lot of money.

Therefore I think it would be worth waiting the three months to try and get your insurance to pay for it, and if that falls through then go self pay. I would not wait a year, you will drive yourself crazy! xx

[thisislou 13]

Hi

I don?t understand what the ?don't have the adequate weight history? is. If you meet all of Aetna's requirements then their should be just a 3/6 month "supervised weight loss program" with your PCP. Saying that - it is simple. I have BCBS and I imagine they are close. It is stated (in BCBS) your beginning BMI is what is used - so even if you lose weight during that time - you are ok.

My advice is to meet all other requirements and have your doctor submit for you. If all else is ok then they should come back with the 3/6 month request. I just went to my doctor 3 consecutive months and documented it - what he said and what I weighed. I also submitted paper work that I was on WW for a year - but don't really think that helped.

It also helped my case by calling BCBS every week or so to find out what was happening. Remember - it is you they are approving - not your doctor and if you wait for them to get back to your doctor - then he to get back to you - time is wasted.

Life is good for me after my VSG. 2 months today and down ~ 58 lbs...

Lou

[Hitorikiri 0]

Thanks for the feedback, everyone!

I've been thinking I'll talk more with the RN coordinator to see what she has to say since I have an appt coming up anyway. If she thinks I have a chance, I'll wait the three months and see if I get approved. If not, then I'll start making plans to get the surgery done elsewhere.

Lou, I was referring to Aetna's requirement that you have two years of documented weight history. I have 2007, 2009, and 2010, but no 2008. Plus I'm not sure if Aetna will count the summer 2009 record for the whole year or if that 2 years will begin on that date. I've been thinking about calling them, but haven't had much luck with their customer service being all that knowledgeable in that past, so I'm a bit doubtful I'll get a straight answer. :/

[TwoStepsBack 15]

When's your appointment Hito? Let me know what you decide x

[peatie 4]

We're in a lot of the same situation. I have Aetna and it requires (per their bulletin) 2 yr weight history... My Dr's office said when they contacted Aetna to get the official criteria for my case, Aetna never once mentioned a weight history was needed. However, all the other Aetna patients in the Dr's office were required to have the weight history (5 years per the Dr. ??huh??). Anyway... it may be that my husband's employer doesn't REQUIRE the weight history... going off on a tangent here, but you might want to find out from your DR for SURE before you start down another path.

Likewise... I consider weights from 2009 and 2010 to be two years, kwim?? Even if they were almost only 12 mos apart...i still considered it ON MY OWN to be within the calendar year of 2009 and 2010 so those are TWO separate years of documented weight history... You might want to find out from your Dr when you go for the RN appt.

I was in the same boat. I could not wait until next summer to have the surgery so i'm doing everything NOW within my power (totally proactive here) to get the 3 mo hoop jumping completed mid-Nov so I can have the surgery in Dec during semester breaks too. You're still not too late in getting started on the 3 mo deal if you do all the first month appts in Sept. Your Dr's office will totally need to work with you on the timeline, but let them know you're a student.. mine totally worked with me once I communicated my issue with them.

I was thinking about doing self-pay in Mx as well...but figured since i have Aetna... I might as well TRY to get them to pay for it first.

Good luck!!! And sorry this was so long winded. lol

[Hitorikiri 0]

Hey TSB! My appt with the RN coordinator is next Thursday. I recently heard from someone on the OH forum that self-pay at the hospital I'm going to is only $9700. I need to verify that but if it's true, even if I do get denied, at least I can still try and get it done in the country, which would be preferable.

And thanks April! That was really helpful! I'm definitely going to try and do what I can to get approved. I mean, as a student, I really don't need the extra debt. :thumbup: Hopefully the weight history will prove to not be an issue after all *fingers crossed*

[susieq 49]

My insurance required a 5 year documented weight history from a doctor. I have regular yearly gyno appts, but there were two times in that five years that I refused to get on the scale! Lesson learned. Anyway, I managed to find one more year with an appointment I'd had at my internist's office. I presented insurance with as much information as I could, and in the end, I was approved. The office coordinator said that my weight and bmi alone would probably qualify me. Anyway, give 'em what you have and hope for the best! Good luck.

[Becca 108]

I would try your insurance first. I had an exclusion and went to Mexico three years ago only to have my band fail me and the aftercare is horrible for Mexican patients in the U.S. (I did receive excellent care while having my surgery, though. The doctors really know their stuff. I just can't afford to fly down there everytime I need something.) I know the sleeve doesn't really require aftercare, but if something does go wrong, at least you have a doctor here. They treat you like the plague when you say you had surgery in Mexico! I now have insurance to cover my revision, thankfully. Don't give up! Hang in there! :thumbup1: