You Gained Weight During Your Pre-Op Diet…Now What?

There are a great many of us patients out there, hoping to get approved for surgery very soon, who are living in fear that the number on the scale isn’t going to move the right way after they’ve completed their “mandatory” pre-surgery diet plan.

“What if I don’t lose enough?”

“God forbid – WHAT IF I GAIN WEIGHT!?!”

The question is how to handle this unfortunate situation. It starts with the surgeon’s office.

Aetna in particular is causing a lot of people concern because their medical policy says “The member must not have a net gain in weight during the program.”

Bariatric surgeons may ask a patient to go on a weight loss program as surgery gets closer because it often helps make the operation safer, especially when done laparoscopically. That is a medical decision made by a qualified professional. What I’m talking about here is very different. Insurance companies try to force people to lose weight as a way to have us prove we are “worthy” of this medical care. If we lose weight before surgery somehow that is evidence that we will be good little boys and girls after the operation and follow all the rules. Ever hear about another chronic disease where the patient has to prove themselves worthy of the only effective treatment for their disease? Me neither!

The question is how to handle this unfortunate situation. It starts with the surgeon’s office. I can tell you there are far too many bariatric programs who will REFUSE to submit the pre-authorization request if there has been weight gain (or not enough weight lost). That is so sad and often so mean-spirited. It is the WRONG WAY to handle a patient’s medical care. Because insurers don’t have evidence supporting this hoop, DON’T FORCE YOUR PATIENT TO JUMP THROUGH IT!

Remember your patient cannot even fight a denial if you don’t submit the request. I’ve blogged this topic in the past. It is a real problem when bariatric programs give insurance companies the power to make decisions which are not in their patients’ best interests. It happens all too often and needs to stop. For Patients’ Sakes Drive The Bus!

If you are a patient who finds yourself in this situation you have 2 clear choices. You can choose to wait, try again on the diet, hope you lose weight and hope they say “Yes.”  Maybe that works for some people.  It doesn’t work for everyone.  There are many others who instead choose to FIGHT. One woman’s story stands out. She gained weight during her pre-operative program. Aetna deemed her unworthy of surgery. She had reasons, but they didn’t care. Her words describe her situation best:

I was denied for vertical sleeve gastrectomy on July 7th. I was denied for a “net gain” during the supervised diet. As I was getting ready for my 3 month required visits, my husband, who is 37 yrs old, had a massive heart attack on Feb 6th…He needed a triple bypass. My world was turned upside down. He was back in the hospital after the open heart surgery because he acquired pneumonia.
I wrote all of this in my appeal letter that was sent out with his discharge paperwork on August 1st they received my appeal and I was denied for my appeal yesterday August 18th. I want and need this more than ever…I’m lost, overwhelmed and simply tired. I’m just totally defeated right now.

The question of whether her sleeve surgery was medically necessary was not a close call. Her BMI was nearly 47 and she had multiple health problems. But indeed she gained weight which went against Aetna’s precious criteria. So this woman was not worthy of treatment, right? I don’t think so.

Shortly after Labor Day we got started. We got her chart, reviewed the plan, evaluated the data and re-started her fight. Today (October 10, 2014) she was rewarded for NOT walking away, even though nobody would have blamed her if she did – because today we obtained her approval. Kudos to her surgeon’s office which submitted her case despite the weight gain, for they gave her a chance to fight. But more kudos to her because she did not stay “totally defeated.” Instead, we get the thrill of reading her reaction when she emailed Kelley after being told the news:

YOU JUST MADE MY YEAR!!
THANK YOU!!!
THANK YOU!!!
THANK YOU!!!
And Walter tooo!!
I am so happy I cannot thank u enough.

“Lost” “Defeated” “Overwhelmed” “Tired” – insurance companies count on those feelings stopping us from moving forward. Please don’t give in. The important thing to keep in mind is that there is always HOPE if you don’t give up. And 20+ years after my bariatric surgery I can tell you that what you stand to gain is worth the fight….you’re fighting for your life – but that’s OK because YOU ARE WORTH IT!!!

Lessons Learned: Celebrating 20 Years As A Bariatric Surgery Patient →

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