AboutKarla K. Expertise I'm very familiar with the four main types of bariatric surgery: Lap-Band/Adjustable Gastric Band, Vertical Sleeve Gastrectomy, Roux-en-Y, and Duodenal Switch. I'm familiar with the Mini-Gastric Bypass and Revisions as well. I'm also beginning my seventh year post-op as a successful bariatric patient--so I can answer questions regarding pre-op, post-op honeymoon, and maintenance phases. I'm less familiar with the nuances of plastic surgery following bariatric surgery--but I do know a bit.
Experience Have been an avid researcher of the science of obesity and bariatric surgery for over ten years now. My professional career used to involve medical device research.
Education/Credentials Master's in Business Administration.
Question Hi. I am considering lap band surgery. I am 5'2" and about 215 pounds. My insurance is a ppom. I would like to know how to go about getting my insurance to pay for the surgery. I know that you have try other ways of losing weight first and I have. I've tried weight watchers, the firm, the 6 week body make over and several diets out of magazines as well as joining a gym and trying to eat healthier and work out at home. I have also had myself tested for food allergies and tried going on a diet that cut out all of my food allergies for 4 months. Nothing is working for me. I keep gaining weight. A couple of years ago my doctor told me that I am borderline diabetic. I have had blood work done since then that was normal but none of the doctors that I have seen since then have run the 3 hour glucose test so I don't know if I am still considered borderline diabetic. However I have had some trouble lately with my blood sugar dropping low. Sometimes as low as like 55 or 60. I believe if I lost weight I would not have the issues with my blood sugar. I am very scared that I am going to be full blown diabetic soon if I don't do something. Any way my main question is this: In order to get the insurance to pay for the surgery do I have to try all kinds of diets while under the care of a doctor or can I just tell them about all of the diets that I have tried? I would like to find the quickest way possible to get insurance to approve it. I realize that my BMI is not 40 yet. I am at about 38 or 39 but I really feel like if I don't do something to lose weight I'm going to be in trouble. I appreciate any help you can give me.
Thank You,
Danielle
Answer Hi Danielle:
Your BMI is 39.3. With your blood sugar issues, some insurance companies may consider you because of your prediabetes--but most want you to have been diagnosed as Type 2. Unfortunately, most will not accept your word that you've tried various diet programs. Most will want you to see a physician and have monthly weigh-ins for at least six-months. Some insurance companies allow you to go through a 3-month educational program--but that is more rare.
If I was you, I would call up my insurance company and find out just exactly what criteria they require. I can't find a bulletin online specifically for PPOM on bariatric surgery. So ask:
1) Do they cover bariatric surgery? If so, which operations?
2) What are the qualifying requirements?
3) What surgeons and hospitals are in-network?
4) What is the coverage like for out-of-network providers?
Take this info to your primary care physician. Tell him or her that you want to do a six month supervised diet--and this is what you need from him or her. The doctor may be fine with you following Weight Watchers (or whatever)...and just weighing in the office once per month. Also, talk about your hypoglycemic episodes with your physician. (If you have a blood glucose monitor, I'd track my fasting and two-hour post-prandial(meal) blood sugars for a week or so to take in with you.)
If they refuse you, you should be able to have a Lap-Band placed both in the States or in Mexico for around $10,000 as a self-pay.
