I have a question about insurance approval...

[spoiltmom 44]

My insurance requires your BMI to be between 35-39.9 AND you must have:

sleep Apnea

Hypertension

Heart problems

Diabetes

I have sleep apnea and Hypertension. The thing is they specify that your hypertension has to be UNCONTROLLED and your sleep apnea must be severe. My Hypertension is controlled with meds and my sleep apnea is moderate.

So if they don't approve me at my current BMI of 37 with my comorbidities then can I just gain 20 lbs to get me at a BMI of 40? If your BMI is 40 you don't have to have any comorbidities and they will cover it no problem.

I'm hoping that I'm overthinking all this and they will just approve me the first time. I so need this and I cannot afford to pay cash for it.

[adagray 1]

Yes, if they deny you based on your comorbidities not being 'bad enough' and you gain weight up to a BMI of 40, you should be able to resubmit and get approval (assuming they are not requiring a weight history at that BMI beyond your current weight). My insurance required that you be at the required BMI for the past two years. Boy, it was a mess because I had lost weight below the required BMI on WW during the past two years.

I did finally get my surgery approved, though (after two appeals). I showed them 5 years of history to document that the lower weight on WW was an anomaly. And, I also brought up a bunch of other issues which may or may not have made a difference. Technically, I did not meet their requirements, though, so I would encourage anyone debating whether or not to go the insurance route to at least try. And, take it through the full appeal process.

In the end it was SO worth it. Not just to get them to pay for my surgery, but the peace of mind of knowing that all of my follow-up care will also be covered.

[SuzanneG 1]

I was low BMI when I started and my insurance company denied me the first time through. Don't be surprised if you get denied as I think many insurance companies automatically deny anyone who isn't Iron clad with the requirements.

Be prepared to appeal and if you don't get through on the first try, you likely will on the appeal. Save the weight gain as a last resort, but it would probably work too.

I have offered my appeal letters up many times on this site and have shared them with many people with 100% success. If you end up needing an appeal, I'd be happy to send you what I have for a sample.

Good luck to you and let us know how it turns out!

[spoiltmom 44]

Thanks ladies! I'm hoping I don't get denied b/c the insurance lady at my surgeon's office said she doesn't do appeals. So I would definitely have to do the appeal myself. I'm just nervous right now!

[SuzanneG 1]

Good luck and keep us posted.