By: Ellen Carl

Ellen Carl — Mon, 25 Jun 2007 21:13:19 +0000

Dear Lulu: Brian here. I had what the doctors consider co-morbidities. Five
of them to be exact. They were all considered chronic and caused my the
obesity. You have not mentioned what your weight/BMI is. That is also a
factor.

You may have some of them and not be aware of them. First was diabetes type
2. Second was hypertension, third was GERD (gastro esophageal reflux disease),
4th was cardio myopathy and the final was sleep apnea. These five factors led
my doctors to issue a statement of medical necessity.

Since my surgery all are gone except the hypertension which is well under
control with oral medications.

I hope this helps you.

Brian in S Floirda

The problem I have right now is that my insurance company have some
criteria I need to fulfil to get funding for a gastric band operation.
They treat acute conditions, but consider obesity a chronic
condition. They will fund me if I have other co-morbidities or other
symptoms but at the moment I don´t.

They have requested a medical report, and this is the bit I am not
understanding very well…

"the reason that we have requested a medical report is because, as you
point out, this does seem to be treatment to cure an acute condition,
however it would be unusual to authorise bariatric surgery, so we need
to refer this to our specialist medical team. We need the information
requested to check whether the treatment can first be considered, to
check whether this meets our definition of an acute condition, whether
the treatment is appropriately recognised as beneficial to your
condition by the relevant medical bodies (I.E. not experimental), and
whether the condition being treated was not present before you joined
us (by onset date we mean the original date that you first noticed
your symptoms, even if this is an approximate date).

We do not pay for any treatment which is specifically to treat obesity
and nothing else - We treat every case individually, and please be
assured that we look very carefully into whether the treatment
required would qualify for benefit, but as this is an unusual case
these are the most specific guidelines I can give - my advice is to
have your doctor include as much information as possible about your
conditions and why this surgery is recommended."

So…I have a doctor who will write a medical report so that I am able
to get surgery, but what on EARTH do I do? Do I have to make up non
existent problems like hypertension or diabetes or goodness knows what
to get treatment for obesity which for me is an illness i´ve battled
with since I could walk…

Has anyone else come up against these criteria, or these kinds of
problems, and how did you get round it??? My doctor isn´t the problem,
he will write any thing on the report, it´s just that I have to tell
him what to write so that it shows I fulfil the criteria for my
insurance company…it is a bizarre state of affairs I know…

What next??? Hugely confused, thanks for taking time to read this far….

Kindest regards

Lulu

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By: Jamey Lancaster

Jamey Lancaster — Mon, 25 Jun 2007 08:45:45 +0000

Have you been tested for sleep apnea? Do you snore? How much overweight
are you? All these things might come into play. How long has it been since
you’ve had a really thorough medical check. All these things might come into
play. I had to pay for my GBS, my insurance was… difficult. So, I took out
a loan to do it. If I need a revision, I’ll have to pay for it. And I
might. I’m not sure that a 100cm bypass is sufficient for me – I’ve been
obese since I was 7, almost 50 years at the time of my surgery.

Pam in Niceville

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Dear all,
I thank you so much for the messages, it has been such a help to me.