Catch-22, Literally

[kczar 166]

I've been trying to lose a bit of weight before my surgery (six month wait due to insurance.) I've been reducing my calories and even started upping my Protein. This morning I realized that if I lose more than 22 pounds during my supervised diet, my BMI will drop below 40 and I wouldn't qualify for surgery. I "only" have one co-morbidity and my insurance requires two if you're BMi is below 40. Although I'm thankful insurance will cover it (and I've met my out of pocket maximum due to gallbladder surgery), it sucks that I could be penalized for being successful.

So I guess I'll set a goal to lose 10-15 pounds until my paperwork goes in, which will either be end of July or end of August. I'm not sure when the insurance asks for a six month monitored diet if six visits with the NUT counts or if I have to do seven. Anyone out there know?

[favoredone 590]

Check w/ your insurance company or surgeon's office.. Most ins use your starting BMI and won't penalize you for losing weight...

[GivingItMyAll 168]

I was told that the weight that counted for insurance was the weight they recorded during my intake. Hopefully you won't be penalized for being successful in loosing pre-op.

[Webchickadee 716]

Sounds like bureaucratic lunacy to me!

I would defiintely check with your insurance company. It makes no sense that they would penalize you for losing weight (thereby increasing the chances of a successful surgery and reducing the risk of complications) prior to the surgery date! It's potentially going to cost them ALOT less if you smoothly sail through everything, and being a lower healthier weight at the time of surgery greatly increases those odds!

Also, I'm jealous! I live in Ontario, Canada. We have government healthcare here, but a long long wait list for WLS (5-7 years IF you qualify). And they only pay for the Roux-en-y procedure, which I am not intersted in having (I don't WANT to bypass my intestines, and make a jigsaw puzzle of my insides, thanks!).

So I've decided to self-pay and I'm going to Mexico on May 14th, 2012 to have to the VSG done. Best money I've ever spent and I'm damn lucky I can afford it (barely!). Otherwise I would have to wait until I'm 50 (I'm 42 now) and have a surgery I'm not comfortable with.

It's very short-sighted of the Province's healthcare system, actually. If I don't lose the weight, it's going to cost them ALOT more if I have a stroke, a heart attack, need cardian by-pass surgery, get diabetes, or hypertension (just a few possiblities if I remain at my current BMI).

They should pony up the money now and save themselves 10x that in the future, because it's almost a certainty that they will paying those big bucks down the road for my care without weight loss now.

[kczar 166]

Thanks for the input, I'll double check when I go to my NUT appointment tomorrow.

Webchickadee, it really doesn't make any sense for them to not cover it. It's like policies that don't cover birth control, but will provide prenatal and child coverage. Isn't that a tad more expensive?

I've been without insurance for ten years (work for a small startup company) and when I had to go to the emergency room with a gallbladder attack last September, I started checking into insurance in earnest. My employer was willing to bump my salary to cover the cost of individual insurance but I couldn't get any! Why? Because of my weight. I had no pre-existing health conditions other than my gallbladder but no one would touch me. Fortunately, there is a government funded program for people like me. I was able to get on starting in January and get my gallbladder removed. That meets my OOP maximum so this is my medical year! No matter what anyone says about "Obama Care", if it wasn't for healthcare reform, I would still be without insurance and probably saddled with a 20-30k bill for emergency gallbladder surgery.

Good luck with your surgery and keep us posted! I've read lots of good things about Dr. Kelly and surgery in Mexico in general.

[Webchickadee 716]

I know it doesn't make sense, but it's the government (and keep in mind when I say that, that I WORK for the proviincial government!).

I think it's just going to take time for them to come to the realization that they need to update their policies. They just started covering WLS (Roux-en-y procedure) about 5 years ago and have been increasing the "quota" for how many patients they'll take and how many surgeons they will qualify to do it. Everything takes time (a long time!). In the meanwhile, people like me are stuck waiting or looking for alternatives.

I had my gallbladder out (laparoscopic cholecystectomy) after I had a serious motorcycle acccident in 1999. They actually didn't catch the problem until 4 weeks later when my gallbladder ruptured! What a mess, they had to do emergency surgery and I was about 12 hrs from going septic, which could have killed me. Fortunately I recovered very quickly and have had no real problems since, other than having some disgestives problems when I eat greasy foods. I usually find that if I'm not close to a bathroom 20-30 mins after such a meal, I'm taking a risk! LOL

Thanks for the good wishes and I will be posting quite a bit before, during (if I feel up to it!) and after the VSG surgery.

I have learned SO much from "lurking" on the board here that I can never repay all of you for. I wouldn't have felt comfortable making this decision (especially to go out of the country!) without all the honest, and detailed information everyone here posts about their pre and post surgical experiences.

Thanks everyone!

Good luck kczar........let us know when you have a surgery date. Cheers!

[kczar 166]

I double checked the list of requirements from my insurance yesterday, and it specifically states that I need documentation of a BMI 40 or more for at least a six month period. That's because I only have one co-morbidity. Oh well, I'm going to continue working on my eating habits and working out, but I'm not going to push myself to lose much weight.

[Webchickadee 716]

Just a thought, but do you have a family doctor or primary care physician who's been following you for the past few years?

They probably have documentation of your weight during that time (at >40 BMI)....so that should qualify towards the insurance companie's requirements. I don't know if they need that documentation ONLY from your WLS surgeon, but I would inquire directly with the insurance company (try talking to a live human being, and get them to follow up in writing to confirm).

It doesn't make sense that they would block you from losing weight prior to your surgery.....it can save them money! You have a lower chance of complications if your BMI is lower at surgery time......therefore reducing their financial exposure!

[kczar 166]

Because of the gaps in insurance, I saw one doctor two years ago and my PCP in January. They may take that but I'm not sure. I'll check with my surgeon's office and insurance to be sure.

[Amie 90]

I was having the same issue in the first couple visits for my 6 month wait. ugh So I decided to stop dieting for awhile, now that I'm a few months in I have started watching my calories, chewing more, and I'm trying not to drink while I eat. Which is REALLY hard. If your doctor is like mine I get my weight taken while my clothes are on so if it comes down to a pound or to I guess I can just slap on some ankle weights, LOL Good luck on your journey.

[kczar 166]

Thanks, Amie. I actually got some good news. First, I found out I only need six visits instead of seven. Then I switched over to my PCP since my surgeon's NUT is leaving to be a stay at home mom. I called his office and he'll fill out one of the forms to allow my physical in January to count as part of the diet plan. So...instead of looking at a September date, it will probably be July! So I'm not as concerned about "losing too much weight", lol.

Keep it up, girl. We'll get there before we know it!

[kayte819 95]

I actually was told during my 6 mos of supervised "weight loss" NOT too lose much for this very reason. My surgeons office said they have.seen cases where the ins co say that the patient seems capable of losing w/o surgery. I decided to heed the advice & didn't diet at all. I ate like usual until the pre-op diet.

[kczar 166]

I agree, Kayte. I'm making changes but not killing myself trying to lose weight. I should get my last visit done at the end of June and will wait till then to really start working on losing. I figure once the paperwork is submitted, I'm in the clear.