Unethical bandsters?

[Alexandra 55]

and i'm not so sure that the gov't guidelines for what constitutes a medical necessity for a band is purely based on scientific research and safeguarding the public's health. i simply don't believe in them like that.

I don't think it is based on "safeguarding" the public's health. It's based on risk/benefit analysis, which is why it seems so way off for banding. The years of RNY and other bariatric surgeries are the body of experience they use to calculate such things. It will be several MORE years and MANY more banding patients will have to be studied before any changes are made.

IMO, there should be a huge divide between RNY qualifications and those for banding. The current guidelines don't take into account the exponential difference in risk level. Someday, we can hope, they will.

[cashley 0]

IMO, there should be a huge divide between RNY qualifications and those for banding. The current guidelines don't take into account the exponential difference in risk level. Someday, we can hope, they will.

Exactly... I was only 5 pounds too light to qualify for the surgery according to the AMA standards... was it better to gain the weight, keep trying the diet route or "fudge" those 5 pounds. I choice heavy clothing, heavy shoes and some stuff in my pockets...

Did it fool the doctor? I don't really care since I didn't want to be the the operating room with open heart by-pass surgery at the age of 45 like my mother was.

I had the money, felt it worth the risk and was doing it whatever it took...

Also, I realized there always has to be a cut-off point... I was just too close to that "cut-off" that heavy clothing worked.

[BeacheeGirl 0]

*bump* to that thought Cashley. I tried to fudge my height and weight when I tried to get insurance to pay for it but I was still denied because I wasn't fat enough and not enough co-morbidties at 5"8 and 225 lbs. A year later, I have gained another 10 lbs (not trying) and have just decided to go to Mexico and pay for it myself. However, I do feel insurance should have paid for mind due to family weight related complications I am sure to get if I keep packing on the pounds, not to mention my heel spurs, dangerously high cholestoral, almost 300!!! and heart palpitations. But i would not have felt guilty AT ALL if insurance would have paid for it had they approved me last year.

[Jachut 487]

Judging by the state of America's health system, I would totally support anyone moving things along in this way. The system doesnt appear to be fair in any way. People can be just as desperate at a BMI of 35 as they are at 40 and a system which will not help people until their problems have multiplied many times (comorbidities) is a stupid one. It costs more in the long run to not help people until they're sicker.

I would argue long and hard against the statement that a person with a BMI of 36 but no comorbidities does not need surgery. Its only a matter of time before they do and it will cost the country and the taxpayers a lot less in the long run to just provide that help before it becomes critical. Most people that get that fat have a problem and will get fatter.

Here, the definition of medically necessary is whether you're fat or not, end of story. If you're obese, you qualify. It prevents lots of people who decide on a band from ever getting as sick as they otherwise would have. I had no comorbidities and BMI of 35 and this surgery has been enormously beneficial to me. Why should I have to wait until I have a BMI if 45 and diabetes, that will have cost our health system a lot more!

[lotsofkids 0]

isn't it just as "immoral" to go and push your weight up even more just to qualify for WLS?

There will always be shades of gray!!!....however blatent lies for insurance purposes is not my cup of tea and not what I want to teach my children. I do feel that it is dangerous to view this surgery lightly and as a cosmetic procedure for the general public to just elect as with having botox or other cosmetic surgery. There are definate risks and post surgery behavior that must be adhered to. JQ Public is not always informed or ready to put in the full efforts required.

My husband is a physician....and was totally unsupportive in my decision to have myself banded. He was thinking long term for my ultimate health and what complications could come from my decision. Of course.....I was doing all my research and speaking very candidly with the doctor/surgeon.....and only because the doctor believed that I would and could benefit greatly from the surgery and that I was a good candidate (no metabolic syndrome problems etc)...... that I continued to pursue the matter.

My husband is slowly getting on board...as he can see that I am taking my health seriously and not expecting the band to do the work for me. I knew I had to intervene if I wanted to be around for the future.My BMI was 35...but with 2 co-morbidites (including a horrid sleep apnea that was ruining my health) I was lucky the insurance approved me...but if they had not....I probably would not have pursued the band...as we have too many financial burdens going on....but I would have continued to try to lose wt the "ol fashioned way......I had already lost 14 lbs from the time was measured with the bariatric program and was going through all the testing till the time I went in for surgery. Now, I have lost an additional 14 with the first month of my band....and hopefully many more to lose!

There are many tests that are performed before you are accepted to have this surgery....they are all for your benefit and to reduce the risks of serious complications. The bariatric nurse......who had roux-en-y gastric bybass 8 yrs ago......had a massive heart attack one week post surgery.....and she could have died! Luckily, she recovered and was able to lose 160 pounds....and she has been an advocate for total awareness of the risks and benefits of bariatric surgery. She still says....it is a daily struggle and she must work at not slipping back into bad habits.

For anyone who is stuck in a rut....and has tried and failed over and over....then it might be time for a life-preserver called Lapband Surgery. But that is a personal journey and must be an informed choice. We know ourselves and where our health is going or not going. We must take an active role if we are to succeed. I am glad that I pushed forward without the blessings of my husband....as I think this surgery will have saved my life and most definately have improved it's quality....let alone I feel I am already walking taller and seeing my confidence increase!

But if people are still going to live at drive through....fast food chains and slouch in the sofa for hours on end......then ask for a surgery to right all the wrongs.....I think it would be unethical for the doctor to accept this type of person as a patient. An informed and motivated patient....that has been tested to rule out any other problems that could be harmful......should be able to have access to surgery....if a qualified doctor believes they will be able to improve their health...regardless of #'s called BMI or scales....if a doc feels the benefit outweighs the risk for you....then you should be able to follow through with surgery. If an insurance co doesn't want to pay....well.....hey....take a mortgage on your home......you might live longer to see it all paid off! Yes it is expensive....but it is the price of a quality car....and I think much more important in the long run.

Smiles....diane : )

[MsButterKup23 1]

I admit that I haven't had a chance to read all the responses (past the 1st page) so for the sake of sounding stupid, I can only offer my experience with the band and obesity.

I had my daugther in October, 2004. I had my surgery for her, to be the mother I wanted to be. One day the truth just slapped me in the face. I mean I asked my self honestly what were the chances I would lose the 150lbs I needed to lose in order to be at a healthy weight? SLIM TO NONE and more importantly keep it off and stay healthy... probably not a snowball's chance in Dallas this time of year.

My insurance company wanted to know what type of programs I've been on and I told them that I tried different diets and nothing worked well enough to get rid of the 150lbs of blubber that had found comfort on my body.

I hope every one finds happiness. :rant:

[jqpublic 1]

I, can see both side of this issue. I ,was at 39.5 BMI I thought about eating a few more fat burgers on my own to beat the system!

And a nice lady from lbt early on told me how I could beat the system, she did it in minnesota! was to get a minnesota address get some mail there health care system would due the rest!

I thought about it! just did not want to commit fraud ( in my own mind )

Im glad she did it because it probley saved her life! with one little lie!!!

I,looked into lapband surgery and my own insurence would only pay for GASTRIC-BYPASS I,watched a program on discovery channel to much cutting for me.

I, lost the weight on my own and help from people here on this site and my faith in God, and being scared of dying!

before I hurt my back last June I worked out up to 14 hours a week, I just plain went nuts with exercise and some starvation due to over exercising!!!!!!!

I, don,t think I, could due it a gain. maybe 50/50

( IT SHOULD JUST BE EASYER FOR PEOPLE TO GET HEALTH CARE ) WITH PEOPLE WHO HAVE VERY LARGE BMI,S SHOULD BE CONSIDERED MOST AT RISK OF DEATH, DUE HEART FAILURE AND ALL THE OTHER PROBLEMS THE COME WITH BEING OVER WEIGHT. THAT IS JUST MY OPION.

AND I, WOULD NOT JUDGE ANY PERSON THAT MADE THAT LITTLE LIE TO SAVE THERE OWN LIFE!

I, THINK WE ALL HAVE MADE, A LITTLE LIE IN ARE LIFE TIME?.. ( I, HOPE THIS DON,T GET ANY BODY MAD WITH THAT STATEMENT )

[Randi 0]

Great thread! I have been thinking a lot about this very thing ever since my recent experience trying to get insurance. Get this -

I had my insurance man at my house & we were filling out all the forms to see if we could qualify for the insurance. One of the questions was - "Have you had any type of surgery in the past year?" I put down a YES & then started answering the questions next to it explaining what kind of surgery it was. The insurance man stopped me. He asked me what kind of surgery I had. I explained to him about the lapband surgery. He stammered a little & then took the paper away from me & gave me another one. He suggested to me that I write a NO in that section. I was STUNNED!! I am an honest person & was feeling very, very uncomfortable about marking a NO. He explained to me that we weren't cheating the system, we were just letting them know that I was indeed healthy. He knew that last year the insurance company had turned me down because of my weight. Now that I had lost weight, he knew that they would still turn me down because I had surgery. He said that because I was a self-pay in Mexico that there are no records in the US proving my surgery & that as long as I continue to go to MX for my after care I shouldn't have to report it.

This system is so FRUSTRATING!! It seems as if everyone is trying to deny you for everything because they don't want to pay for it!! I can easily see why people would want to put rocks in their shoes & do all that crazy stuff. You mean to tell me it's healthier to gain 20 lbs. just so the insurance will cover you?!?! SOMETHING IS VERY VERY WRONG ABOUT ALL OF THIS!!!

It seems like the system is cheating US, not us cheating the system!! :tired

So, the moral of the lapband story is . . . if you're overweight we won't cover you and if you're not, but you had surgery, we still won't cover you?

If that's what we're up against, the road ahead could be very long for someone who has to change insurance policies after they're banded (i.e. change in job). From your post, it seems like it's being looked at as a pre-existing condition.

[lotsofkids 0]

I have seen your postings before and I must say you are an inspiration for a lot of folks here. You have accomplished what many have tried and failed before you. Losing wt the 'ol fashioned way! There are a lot of people visiting this site who are looking for answers and may be turned down for surgery or just afraid to go ahead with the surgery. I hope they see some of your posts and at least try to get the mental stamina to overcome their wt issues.

And yes, we are all fallible...I may speak of high manners and morals...but of course, I have dirt in my history that I am not proud of. But now that I am older and wiser....I feel as an adult...I do have a responsibility and an obligation to try much harder to "do the right thing" and keep my little corner (and my concious) clean. It is a life journey and struggle to seek to better one's self on a daily basis.

Bottom line on this subject......I feel if a reputible Doctor...finds that the surgery should improve your health and that if the benefit of surgery outweighs the risks for you personally....then the insurance companies should be pressured to help you to achieve better overall health. It would be in their long-term interests as well. This supercedes any numbers or cutoff requirements. It should be up to the doctor if he feels you can obtain a healthier life with the surgery. Now, maybe the Insurance companies can ask for a second opinion through their own doctors so that there will be some checks and balances and that it is being done for the right reasons. Or they can ask that you be under the care of a doctor for 6 or 12 months prior...etc...They can smooth out all those fine details to eliminate abuse...but if a reputable doctor says this surgery will help you to be healthier.....and you pay and have a current inforce insurance policy....then "I" feel it is UNETHICAL for the insurance companies to deny you a healthier life. Now, they can set high co-pays and upfront costs for this type of surgery ...but those are the minor issues. They should pay if a doctor feels you need it.

Whew....now I will take a breath.

I hope everyone has the opportunity to better their health.

hugs and smiles....Diane : )

[NewSho 20]

Most of us seem to agree on why cheating is wrong, but there's something else being said (or left unsaid)...

Operative words: if they truly need the surgery. YOU may feel that at a BMI of 39 you "need" bariatric surgery, but you were otherwise perfectly healthy. .

Again, our opinions are based on our own experiences and beliefs, right?

I believe that insurance, like WLS, is a tool - and I try to use (not abuse) my tools for their desired purpose. I needed a Weight Loss Surgery but I went in to this process knowing this was my only hope. But I think there is an undercurrent here that goes beyond 'people cheating the system to get over.' What I'm reading (and sensing) is that there is some disapproval over those with lower weight getting this surgery even if they can fully qualify by insurance standards.

No, it's not just a sixth sense, I definitely read it.

What if someone who thought like some of those who are here - made the decision to approve or deny me?

It's amazing that based on what I've read here, some might deny me (or others like me) because of my slightly lower start weight by WLS standards.

I was very pro-active about my weight and trying to fight my obesity. Was I successful ? Not quite, but I fought at it. So why does a person with lower start weight (who is still obese mind you, which technically I was until just a few short months ago) seem less deserving to some of you had higher start weight? It's unbelievable.

In other words, even though I started in my 200's and decided to put the breaks on being obese, I don't judge those who wait until they are in their 300's and 400's to try to address the problem. But on the other end, there are many who either had higher start weights and had full insurance approval or those who had lower start weights and understandably chose to self-pay - who seem to have no problem denouncing (or simply chiding) those who approached getting this surgery differently.

Why is that? I use myself as an example. I had 7 different consults with different bariatric surgeons. Only one said he questioned whether I was heavy enough (but since I was already fully approved then, I was desperate enough to get back on phentermine and trying to chip away at the mountain of weight I had on me before surgery).

But for the purposes of insurance coverage, perfectly healthy people who happen to have BMIs of 39 really don't need insurance to cover their surgeries right now. There are other, sicker people in line ahead of them. And that's the way it should be...

That's the way it should be?

I can speak that there is no "line up by start weight" system that insurance companies utilize to approve people for surgery.

As I believe you are, Alexandra, I'm relatively tall. But I was inarguably obese by all practical purposes. I was about 38 or 39 BMI at full insurance approval , depending on how successful my diet efforts were. I needed the insurance company to cover mine because even at my (previous to being ill & disabled, then very high) income it would have taken me at least 2 years to save the $25K for LapBand or $35-$40K for RnY Bypass surgery. (In those days, medical or surgery financing wasn't as common as it is now and I didn't own a house to refinance or use for a collateral loan.) Fearing how much fatter I'd be in 2 years, I decided to take the approval route. So I was approved with no co-morbs but I did have a nearly lifelong fight with obesity and a long diet history.

So I was a 'perfectly healthy' person who needed surgery. Later, I learned, in my other capacity as a (now former, thankfully) insurance company employee, that people get denied for 1 BMI point or 5 lbs every single day. I think you mentioned in an earlier post that you didn't believe it happens routinely - but it does. Just as people with 50 BMI's get disqualified for absolutely unquestionably unfair reasons that have nothing to do with qualifying. The system is not quite working for a lot of people. That's me, admitting that I judge insurance companies and our health care system - yet some of here won't admit that we judge those who have different reasons for approaching this surgery when we did. As Diane as some other posters mentioned, without insurance approval many people could have never afforded or even justified having this surgery. That doesn't justify cheating the system in many people's minds which I understand - but statements "people with a 39 BMI who are healthy" aren't as deserving or aren't as priority cases, does seem to be a form of judging to me.

Again, the continued discourse is fascinating.

Happy Band (And Life) Journeys To All...

[pplqueen 0]

I just want to add that I work for 125,000 attorneys for across the US and when I reach my goal weight I will be poster child for this surgery and I will lobby congress, insurance companies and anywho else that will listen. They should pay. If a person has proof that they have really tried in the past, they should pay. IF they have a family history of HBP, heart disease and the other co morbidites that we talk about. They should pay. They pay for preventive medicene ALL DAY LONG. This should not be any different. For pete sake, companies even pay to rehad drug addicts and alcoholics. Therefore they should make the plans available that cover this surgery. Pet insurance? Are your dogs more valuable to your company than you are? Even though providing per insurance is cost free to the company, its the principle. Don't you think?

[lotsofkids 0]

I started out as a lower BMI of only 35 w/co morbidities. I told the doc today at my 1st fill appointment....I believe my choice to have this surgery has saved my life. I was spiraling downward in my health and I personally did not tolerate the stresses of overwtness very well. It was a no-brainer that I needed to intervene or look forward to a heart attack in my future. My DH is a physician.....said some people much heavier than me....may have carried a stocky frame and have adapted ...they can tolerate the wt better.

For me.....my construction...I put on wt later in life....and it seemed to be a big stress with cronic shortness of breath, apnea, hypertension etc...

So whether the numbers say you qualify or not.....you clearly know how you feel and if this wt is going to effect your overall health.

I am sure this was a lifesaver for me....my dad had a major heart attack at only 42 and my mom dropped dead of one at age 61. It was only a matter of time before I would follow suit. I didn't need to jump into the 40+ BMI's.....I might not have even survived getting to that wt...LOL

My apnea already went from mild to severe (and wrecking havoc on my daily life) I was starting to get pre-hypertensive....and I was found to have fatty liver ds.

I started out at only 228.....I am now 197 and melting.....This surgery meant survival!....for me! and I am sooooo grateful to have had the opportunity to get a chance to change my course.

If it is medically indicated........the Insurance Companies should pay....regardless of the numbers!

wishing you all good health.....diane : )

[katt 0]

By Jove I think I've got it! We have all beaten and beaten around the old insurance bush. And I have read the words 'medically necessary' over and over. That is the problem. We are forced to let someone or something else make determinations for us. Define medically necessary. Can't do it. It's different for everyone. It's damned if we do and damned if we don't. Rely on the insurance system and get screwed. Change the system to a univeral coverage and get screwed. It's the plight of humanity. I'm just very grateful that by hook or by crook (and some borrowing) I was able to come up with the bucks to be self pay. I think that anyone who is obese and has struggled to lose should be able to get WLS if they want it. Regardless of numbers and regardless of insurance company policies on not paying for anything. Katt

[rorysmom 0]

"And I have read the words 'medically necessary' over and over. That is the problem. We are forced to let someone or something else make determinations for us. Define medically necessary. Can't do it. It's different for everyone."

i totally agree. medical necessity is relative and personal.

and it shouldn't be based just on physical medical necessity either. the emotional turmoil 25 - 40 pounds that won't come off wreaks on a psyche over 10 - 15 years is immeasurable. the missed family portraits, feeling fat at every "fun" event, wondering if you might find love if not for... i could go on. but y'all know.

[Fauxnaif 1]

It seems way too easy to take the moral high ground, especially when you're already banded or you meet the BMI or weight requirements for the band. I think it better not to judge until you walk a mile in the other person's shoes and go through THEIR daily struggles with obesity.

Well, some of us who have the band already did have to pay for it ourselves. I had a BMI of 47 and had to self-pay. I am not wealthy and it involved a huge sacrifice on my part. I do not begrudge anyone who genuinely qualifies for having the band, but I am a bit jealous of people whose insurance paid.

And, you can sugar coat all you want, but it IS fraud for someone to lie or fudge to try to get the band. This kind of crap is probably why my insurance wouldn't pay.

I have had enough run around with insurance companies (try getting treatment for mental illness-they make it so hard so a person will just give up!) to know that it is tempting to lie. But the other insured people are the ones who are paying for your indulgence. Do you really think the insurance companies are going to cut into their profits? No, they will just reduce coverage in the future!