Self Pay or weight for insurance That is the Question!!

[golfbuddy98 3]

I am struggling with what to do. I have a BMI of 40.5 and have CIGNA if I do the six month diet and lose weight I know I will not be able to get approved for the surgery. Then I will in a few month be back above the 40 BMI. Thus the cycle will start again. Or I might get approved anyway I am not sure how it all works but then I will still be 6mths or more out. I a so ready to start my weightloss journey, Should I self pay??? Please give me your opinion!

[Disney 20]

My insurance (Tricare) does not cover VSG so I had no choice, but I could wait for them to, I guess. But I'm like you, I am ready NOW, so I am going to self-pay. I have a feeling i'm not gonna mind that monthly payment very much when this weight starts falling off.

[Rootman 1,101]

This is a quandary that only you can answer. I know of one other person that was in the same boat as you, he started to lose weight during the 6 month supervised diet. His dietitian told him on the sly that if he continued to lose weight he would be DISQUALIFIED from having surgery. He then started shoveling it in as fast as he could and actually GAINED weight He had to LIE about it and insist that he was actually TRYING to lose weight. He had to be careful when he went for his psych eval to make sure he appeared to not be sabotaging his diet He passed and about 9 months after applying had his surgery.

As long as this type of policy is being held in place you can be sure that people who really need it will be denied and some will play the system to get what they want and a few will eventually qualify.

I elected to NOT play the game and had self pay surgery in Tijuana MX. It IS risky and there is NO follow up other than phone consultation on your dime.

[bloomin_vjf 1]

Hey Golfbuddy,

My surgeon received insurance appoval for my sleeve based on my weight and BMI recorded during my first consultation. The insurance coordinator said there's an assumption by the insurance company that I would lose weight before surgery, in preparation for surgery and to show an ability to lose weight by following a plan. Actually, during the informational seminar, the nutritionist told us that some patients would have to follow a liquid diet 2-3 weeks (losing as much as 20 lbs) before surgery to shrink the liver.

I would talk with the insurance coordinator in your surgeon's office before becoming discouraged.

Good luck!!!!

[M2G 1,836]

Call your insurance and find out specifically what is expected of you. My insurance guidelines were approval based on a BMI of >35 WITH a co-morbidity, or a BMI >40 (no co-morb required). AND MY WEIGHT AT THE LAST 6 MONTH VISIT WAS USED TO DETERMINE ELIGIBILITY. Your insurance may take the weight recorded at your first visit. So it's imperative you call and talk specifically to the person who will be making the decision (like a Nurse Case Manager, or someone similar will probably make the decision.)

I did all of my 6 month evaluations with my surgeon's in-house NUT (nutritionist) and she did not have me do any type of pre-op diet. Instead we spent the 6 visits talking about life AFTER surgery, what to expect, food options and choices, etc. My weight remained almost identical each month. I used the 6 months to start taking Vitamins, focus on less carbs, increase my Water intake, experiment with food, and practice eating and not drinking at the same time, etc.

If my BMI had slipped below 40 at my last visit, then I would have been disqualified. Lucky for me my BMI hovered around 44 the whole time (and I have no co-morbidities), so I really wasn't at "risk" of going too low. Plus my surgeon didn't make me do any type of Pre-Op diet, just Clear Liquids 24 hours before surgery.

Find out all of the details before you make your decision!

[tntransplant06 20]

I was selfpay--my insurance did not let me do any kind of weightloss surgery, I had no choice. I think I'm ok with that b/c I was in charge and didn't have to jump through all the hoops I see people on here having to do. It seems like a big circus act sometimes. I had mine done in Detroit and it was only $10,500. Money well spent, less than a new vehicle.

[leeblewb 9]

I too have Cigna. I jumped through their hoops and was approved on the first attempt. It took me about 8 months to jump through their hoops though. No one knows what your financial situation is but you. If I had the option of self pay, I probably would have gone ahead and had the surgery, we were just not in a financial situation where that was feasible. IF you are waiting for the six months though, you can go ahead and get all the other requirements done while you are awaiting that time to pass.

[educationrulz 18]

I agree with Mommy2Girls. Get the specifics from the insurance co. before you make any costly decisions. My insurance company told me that I would be disqualified if my weight went too low, but I had more wiggle room on my BMI than you do. But, I've also read that some insurance companies use the 1st consult weight as the qualifying weight since they want or require you to lose weight on the supervised diet.

With that being said, DON'T LOSE ANY WEIGHT OVER THE NEXT 6 MONTHS! I know that's counterintuitive, but since medical insurance can be a big game sometimes, why can't we play the game too? Short of criminal acts and blatant immorality, do what you have to do to get your surgery paid for - if you can take the 6 month wait. I intentionally held back on my weight loss efforts so I wouldn't even have to worry about this issue. It didn't hinder my qualifying in any way. But, again, that's an insurance issue.

It was worth it for me. I got to explore my issues through 6 months of insurance subsidized counseling and I spent between $1100 and $1300 for everything involved in my VSG, including preop visits and tests (copays), surgeon's program fee, hospital stay and medications. It was well worth the 6 month wait and the insurance hoops. Having said that, if I had not been able to do this through insurance, I would definitely have gone the self-pay route. That's when bank robbery might have been involved. Just kidding...

[lucill35 73]

As the others have stated, I would look further into your insurance requirements before making any decisions. My insurance only paid for bypass or lapband after a 6 month supervised weight loss program. I have a high deductible insurance so it would have cost me close to $4000 with insurance and I didn't want either of those surgeries. I went with VSG in Mexico with Dr. Aceves and although I have only been sleeved for a week, I feel like that was a better choice for me. I got to have the surgery I wanted, when I wanted and was in control of the process.