Weight Loss Surgery - Good news? I'm not sure.




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VeggyMom
12-12-2005, 06:18 PM
I was all set to be a self-pay. Then I find out that my dh's HR department (known for being a bunch of total idiots) gave us outdated paperwork. Turns out that our group plan under Cigna does cover 'medically necessary' WLS (RNY and Lap-Band).

This is potentially good news. Except for the little problem of dealing with Cigna, whom I have found to be difficult to deal with under the best of circumstances and who is notorious for denying WLS requests.

Even for people with much higher BMIs than mine and who have comorbidities (which I do not).

So looks like I'll have to start a physician supervised diet (since none of my past diets have been specifically supervised and documented in the way that Cigna requires) and push all of my plans back by at least 6.5 months.

In some ways this could be good - if Cigna pays. If I go though all of their hoops and then end up being a self-pay anyway then it will be a particularly bad thing.

So I'm not sure how I feel right now.

Carole


hubs
12-12-2005, 08:48 PM
Here's the best news Carole. The best news is that with the supervised assistance you may find you do quite well in the next 6 months or so and that the surgery isn't necessary. I hoping that will be the case for you.

jiffypop
12-12-2005, 10:23 PM
hmmmmm. let's look at this as making lemonade out of lemons... no matter what happens in 6-7 months - the diet works or doesn't work, you lose weight or you don't - you will have some excellent habits under your belt should you decide to go for the surgery.


VeggyMom
12-13-2005, 08:31 AM
jiffypop -

That is true.

I am curious though ... with the 6 month medically supervised diet, what are they looking for?

Are they looking for me to loose a lot of weight? Are they looking for me to be unable to loose weight? Are they looking at my ability to be compliant? Are they hoping that I'll loose just enough weight to fall below a BMI of 40.0 and then not pay for the surgery?

VeggyMom
12-13-2005, 08:47 AM
Thanks hubs! I'll hope for that as well - but after almost 2 decades of yo-yo dieting ... I'm not sure how much hope I have for doing it on my own. I've made some significant changes to my lifestyle in the last couple of years. I'm now a vegetarian. I focus on eating high quality whole foods. I don't have a lot of problems with behavioral changes - but I never seem to be able to know when I am full.

I'll give it my all. But I have either lost the ability to recognize when I feel full or my stomach is so big that I cannot get full. So while I'm eating foods that are excellent "diet foods" I'm not loosing weight.

But I'll do whatever my doctor sugguests.

hubs
12-13-2005, 09:26 AM
veggiemom, just so you know a little about my history... I had to gastroplasty surgeries. The first one 11 years ago, the second one 5 years ago. I lost nothing with either surgery due to metabolic complications. You wanna talk about frustration... I can understand how you get to the point of feeling NOTHING will make a difference and with surgical complications from my WLS on top of the metabolic problems I have felt pretty dismal.

Ultimately, I had to figure out what to eat and how to eat to MAKE my metabolism respond anyway. To this day, when I read of others who have WLS and who respond quickly I feel envious. Because even compared to the restrictions of WLS my struggle has been horrendous and continues to be. I've lost damn close to 150 pounds and NONE of that came through the WLS.

So, I just wanted to say that like jiffy suggests, sometimes you have to make lemonade for your own sake. It really doesn't matter what the doctors want. And lowering your BMI is a good thing. I know you want the assurances WLS 'can' offer. But there is always hope and I certainly don't say that in a superficial way...

MrsJim
12-18-2005, 11:46 AM
I am curious though ... with the 6 month medically supervised diet, what are they looking for?

Are they looking for me to loose a lot of weight? Are they looking for me to be unable to lose weight? Are they looking at my ability to be compliant? Are they hoping that I'll loose just enough weight to fall below a BMI of 40.0 and then not pay for the surgery?

Not a WLS patient but I'd like to offer my two cents if you don't mind :)

I think what they are 'looking for' is that they want to ensure that you'll be able to be compliant, and have as successful an outcome as possible, personally.

From what I've read (check our Big Orange Babe's posts) in the past (not all THAT long ago) basically surgeons would do the surgery, and release the patients with some brief instruction, perhaps with a few followup visits. One thing I've read over and over again in post-op patient's experiences is regarding "head hunger" and not really knowing WHAT to eat - it seems to be quite a shock and surprise for many to discover after surgery that they still have the desire to eat the same foods as they did in the past. Pre-surgery education would reduce that considerably for many IMO.

It appears that most of the WLS surgeons and facilties which offer WLS have realized that they need to offer not just the surgery, but pre-op and post-op support and education to make sure that their patients know what to expect and work on those oh-so-necessary permanent lifestyle changes PRIOR to surgery. For example, here are Kaiser-Permanente's requirements (http://www.permanente.net/kaiser/pdf/23785.pdf):

Once you attend a surgery orientation, it may take several months to over a year before you are given a surgery date. This allows the surgery team at the facility enough time to make sure that you are medically stable and in good mental health before the surgery. Because each person has different needs, the program and timeline for surgery will be tailored to meet your individual needs. A lot will depend on the following:

Your current health status. Surgery candidates with uncontrolled conditions such as diabetes or high blood pressure are at higher risk for surgery complications. Your health status before surgery could interfere with how quickly you heal after surgery. Once you achieve better control of these conditions, you can usually proceed to surgery.

Your psychological and emotional readiness for the surgery. Surgery candidates with eating disorders, depression, or anxiety may need to
delay surgery until the conditions are properly treated and under control.

Your demonstrated ability to adopt the suggested nutrition and physical activity lifestyle guidelines. Remember you will need to live with these
changes for the rest of your life.

Jiff of course is far more experienced and knowledgeable than I in matters of WLS...but I think of the process as similar to getting a drivers' license - they don't just *GIVE* you a license (at least here in California) after you turn 16 when you ask for it - you have to go through training and demonstrate that you can safely operate a vehicle, know the rules of the road and the laws etc before you get one - think of the six months' as your 'training' to learn those healthy permanent lifestyle changes that will give you the greatest chance of success and at the same time reduce post-op risks.

Any competent surgeon is going to desire that his or her patients have the best possible outcome...and I know that insurance companies are generally looked upon as the villians in this, but think of it this way - THEY want you to have an optimal outcome too, if you look at it in terms of dollars and cents for the insurers, having to do revisions and other types of emergency re-operations because of noncompliance on the patients' parts would be VERY expensive...KWIM?

jiffypop
12-18-2005, 06:42 PM
aaahh. mrsjim. wise as always.

sorry i haven't gotten back sooner - life seems to be interfering with a lot!

basicallym in my experience, docs do indeed want to see compliance - and motivation. so many people - you wouldn't believe! - have never dieted! the director of the center where i went said that a 600 pound man walked into her office wanting the surgery. she asked for his diet history. he said that he'd never dieted in his entire life!!! he wanted the surgery so that he could lose weight and still eat everything he wanted to! she threw him out of the office, with the advice to try diet and exercise first.

i also suspect that they're looking to establish some sort of a relationship with their patients. i think they want to understand more than just what the pysch evaluation uncovers.

the reputable surgeons and programs require some sort of delay - whether it's in terms of jumping through hoops or a period of supervised diet. it really does weed out the people who will most likely pay attention from those people who just don't understand that the surgery is a tool, and can be out-eaten, and otherwise out-smarted.

VeggyMom
12-18-2005, 07:54 PM
Just to clarify ...

I am not questioning why a doctor (or particularly a bariatric surgeon) would want to know about a person's diet history. I am fully cognizant of why a doctor would want that information in evaluating a patient's need and likely outcome with weight loss surgery.

I am questioning what the insurance company is looking for when they set ridiculously difficult standards for what does and does not constitute a "physician supervised diet". I am questioning the wisdom of decisions being made for real patients with real medical needs by a bean counter who may never have worked in a medical setting at all and whose entire education is in accounting or business management.

I am talking specifically again about insurance companies putting up ridiculously impossible hurdles. Not doctors.

In fact the sugical practice I have chosen to work with is extremely conservative in both their patient selection criteria and their after care regimen. It is one of the reasons I chose them.

But again - I was not talking about my doctor but about my insurance company.

Both the psychologist and the surgical group are looking at a totality of one's health, weight and diet history. They consider any notation of diet attempts and consultation with a primary care physcian. Whereas my insurance company requires 6 months of monthly visits to a physician, meetings with a nutritionist and documented behavioural therapy.

The insurance company is requiring far more to qualify as compliance than any doctor I have ever met has required, suggested or prescribed. Including a bariatric physician whose entire practice is the non-surgical treatment of obesity.

This particular insurance company has a reputation among both patients and physician's office for setting compliance standards that are difficult if not impossible to meet.

So my question was strictly - What is the insurance company looking for in regard to their 6 month physician supervised diet. Not what is the doctor's office looking for.

Which in no way reflects my attitude toward compliance with any physician order or my ability to comply with those orders.

hubs
12-18-2005, 08:00 PM
VM, I hear your frustration with what should be strictly a medical decision and not one steered by the 'bean counter' as you put it. Of course its their job to spend as little money as possible and liability is around every corner. I don't know this company but it may even be possilbe they have faced litigation in the past with patients who have had less documentation and have suffered complications. Or your intuition that this may be a list of requirements designed to eliminate your eligibility could be bang on.

I wish you well in any case. And I also wanted to say that although your question was about insurance, its an important question to have answered regardless so I'm glad you brought it up.

jiffypop
12-18-2005, 10:44 PM
oops. i read all the replies and then jumped in. frankly, i've heard that cigna is the worst, at least these days.

it's truly appalling that a decision that should be between the doc and the patient can be vetoed by bean counters. i suspect that they're trying to see who will give up first!