At a lost and need some advice

Hello to all as I am a new member. I am hoping that by posting something, that someone, somewhere could help me out even though I am brand new to this kind of thing.

After much research I have decided to get the lap band procedure. Knowing this would be an uphill battle, I first tried to find a doctor who would accept my insurance. (Anthem Blue Cross/So. Cal. HMO) I first stumbled upon Dr. David Oliak. I found out that I could be covered by insurance, I filled out the online forms and sent them in. I had a phone consult only to be first told yes, I was a candidate to no I was not and then felt dicriminated against because of my BMI. Accoriding to Dr. Oliak's office, for my insurance to cover this I had to have a BMI over 35. Well mine is 32.8. According to the CDC I am considered obese and according to Dr. Oliak's website (Jan. 2009) if you have a BMI of 30 and above they can help you. Well..... so much for tricky advertising. If you are a cash pay patient, then you may waltz in with cash in hand ($16000) and they will do the procedure. You just have to have a BMI of 30 and above. However if you go through insurance you must have comorbids and a BMI over 35. So sorry, we can't help you unless you can pay cash. So after round one, I am defeated.

Round two, I head to my primary care physician for a follow up visit as I have high blood pressure, small hiatel hernia, horrible back and bilateral knee pain, (mutiple surgeries on both knees and three herniated discs in my back) poly cystic ovarian syndrome, constant parade of migraine headaches and shortness of breath/edema due to congestive heart failure. We discuss that my BMI is 2.2 points less than the suggested 35, but with my comorbids, my age (40), the fact that I have tried every freakin diet under the sun, and I appear to be going in the wrong direction at a time in my life when I so desperately want to move forward and can't due to health issues, my doctor puts in a request to Monarch to look into this surgery. Just shy of a miracle, Monarch approves a consult within 2 days to see Dr. Peter Laporte at Lite Dimensions. So I embark again on a online application and my hopes are flying so incredibly high that I will jump through any hoop to have this done. After a lengthy process and phone tag with Didi in the office, I again fall apart into tears because Dr. Laporte won't consider me a candidate because my BMI is short of some national requirement. Hmmm.... National requirement? Why doesn't Dr. Oliak have a "National Requirement" and or does cash over-ride all? Even with the prescripitons I take, and being completely uncomfortable 100% of the time, physically, socially, and emotionally, I still do not qualify and thanks for calling. Round two and I am again defeated.

So I have picked myself up again and am prepared to call Monarch to discuss as to why would they send me to someone who won't even let me in the door! Why would they get my hopes up like that? I was even told that maybe if I could gain some weight to reach this magical number of 35. OMG... if I did that, not only would I need a new wardrobe as I am near busting out of what I have, I am also already so miserable, my blood pressure and headaches combined would put me what feels like I would have a stroke. And for what another 16 pounds? Not only is it dishonest, but most importantly I can't put myself through that kind of health risk. I am beyond miserable enough.

Please don't get me wrong, I understand that there are guidelines that have to be followed to ultimately protect the patient and the surgeon. And I am not dissing the two surgeons that I have mentioned here. I have researched them both and know that they are quite capable and committed to helping people like me, but just not me personally who is 2.2 points away. I am at a loss and other than calling Monarch, I have nothing left. I have no idea where to turn to as I cannot bear another disappointment to be told that I cannot be helped. I am hoping that someone knows something that I am missing here. I know that I am there, that I am ready to have this procedure to unlock my life from so much that is weighed down literally by weight and health issues that take so much out of me. If anyone has any advice, it would be more than appreciated. I am open to hearing anything other than have you tried dieting?

Thank you so much for taking time to read this.
Californiagirl20

Be prepared for the harsh truth.

Insurance companies are in the business of making money.  Bariatric surgery is expensive, and it is expensive THIS QUARTER (they don't care what happens next quarter, because you might not be insured by them next quarter -- you could lose your job or die).  The fact that many insurance companies cover bariatric surgery AT ALL has been an uphill battle.

The NIH has set the standards for qualifying for bariatric surgery at a BMI >40 or >35 with one or more serious comorbidities.  This has been embraced by the ASMBS, the bariatric surgeon's professional organization.  The insurance companies have adopted these standards as well, because the fact of the matter is, they are rationing health care.

I am sorry if you feel like your life is compromised by having a BMI of 32.8.  Many of us who were MO or SMO before having bariatric surgery would be HAPPY to have a BMI of 32.8.  I'm sure it is a problem in your life, and you feel entitled to have bariatric surgery to deal with this.  But the professional organizations and insurance companies have set standards for qualification for WLS and you don't meet them.  You are just going to have to deal with that fact -- NO INSURANCE COMPANY WILL COVER BARIATRIC SURGERY FOR YOU.  You may as well stop torturing yourself trying to make that happen.

You should be happy to know that some surgeons will consider risking operating on you AT ALL -- even if on a self-pay basis -- at your BMI.  You should consider doing so.  Perhaps you should consider going outside the US to keep costs down.  If you need to make this happen, THIS is the route you should be focusing on, because (I want to make sure you understand this)NO INSURANCE COMPANY WILL COVER BARIATRIC SURGERY FOR YOU.

If you think your situation is bad, there is AMPLE evidence that the intestinal portion of the duodenal switch procedure will CURE type 2 diabetes -- a life-threatening disease -- in non-MO people.  The procedure is offered routinely in Europe, South America, India, Saudi Arabia -- but NOT in the US.  People have to self-pay for this procedure outside the country, because they can't even self-pay in the US for it, in order to save their lives.  And of course, the insurance companies benefit for free, as the patients' health care costs drastically decrease after their self-pay surgery.

Now, turn your attention to doing what is necessary to get what you want as a self-pay, and stop wasting your time, attention and anger on a completely lost cause.

Claifornia Girl.
The Dr's are not discriminating against you because of the bmi of 32.8/.  The standard set forward by the insurance industry as well as American Society of Metabolic and Bariatric Surgery, as well as the National Institue of Health.  So they are not personally discriminating against you.  There has been a study to show that surgery will help a pt with a BMI under 35 (this is a european study on Diabetes) however, the insurance industry has not bought into it. Yes Dr's will do it but, the insurance company will not pay for it as it is not their standards.
The standards for  most insurance companies are  BMI 35-39.9 with 2 comorbidities ( obesity related complications i.e: high blood pressure, diabetes, sleep apnea, etc). Or a BMI of  40 or great with no comorbidities.  These are the guidelines and many insurance companies expand upon this. 
Sorry, that I do not sound supportive I am.  I also believe in the standards and that the appopriate patients arrive at surgery safely. 
For more information you can go to www.asbs.org
Please do not try to gain wt it isn't healthy for you.
Best of luck to you
Liz

I just sent you a private message. Check your email.

Nice.  You're posting on a public forum that you and your surgeon committed insurance fraud.

I suggest you delete this post IMMEDIATELY.

Thank you to all who did leave a comment and or emailed me regarding my late night post. I would like to say that I am not here nor did I have the intention to whine or perhaps discuss a BMI number that maybe that others would wish to have. My numbers are unhealthy for me and me alone. I am not here to judge others based upon their number and life cir****tances for why they chose this route. I am just happy that they did it. That everyone out there on this website did something for themselves to help them regain their lives back in all aspects that are important to them. This is the chance that I am seeking. I stumbled across this website and thought maybe I could find some support here. I realized I opened up the forum to give me any insight other than have I tried to go on a diet, but I wasn't here to hurt anyone's feelings and or be told to get over it or move along. I came here looking for support to see if there was anyone else who faced similar challenges. I came here in the same regard as the rest of you. All I needed was some support.

Please keep checking with your primary dr. That is where you need to start. Maybe you have co-morbisity's  that you don't think qualifies. Have a full physical. As far as suport I agree with you not all people on this site are suportive. Some people can be rude a crude and unsuportive. My personal oppinion.  Please let me know if this helps and don't let other people case you away. I would like to here from you again. Thanks and Good luck Cathy