Advice on how to get approved?

[t2dav 17]

Hi, I have highmark BCBS (railroad ins). I called and requested my insurance contract details concerning lap band, they will cover 100% if your BMI is over 40 or if you have a comorb with a BMI of 35. My PCP preformed labs and I have high cholesterol, asthma, insulin resistance, and my BMI is close to 39.7, is there anything anyone can recommend for me to do or document? Do you think I will be denied for just finding my cholesterol? I have been on rx diet pills off and on for over 5 years. Thanks in advance.

[Lisserlou 11]

Go back through your medical records for the last 5-10 years. See if you can get access to your doctor's (any doctor you've seen) notes that document your weight, or better yet, your BMI. Showing that you've had a long history of obesity will help. I also documented all of the weight loss programs that I tried and eventually failed. Like, with Weight Watchers, I even sent in copies of my weight trackers. My insurance company approved within a week -- and I have absolutely no co-morbidities (blood pressure, cholesterol, blood sugars, etc. are all excellent), but my BMI was just over 40%, and that's what helped. If you can get a letter of medical necessity from your primary care physician, that would be great. Good luck!!!

[Jendkopp 62]

I would recommend getting a sleep study done, because you may have sleep apnea, and that's a comorbidity that reduces the bmi requirement to 35. I don't think high cholesterol will count. I did not have a 40 bmi for a full 2 year period, so aetna initially denied me. However, my surgeon did a peer-to-peer review with aetna and explained that the period in which my bmi was below 40 was when i was on diet pills (phentermine), and i got approved. In the interim between the denial and the peer-to-peer review, i did the sleep study. After i found out i was approved for the lapband, i learned that i had sleep apnea. Had i done the sleep study earlier, i probably would never have gotten denied.

[t2dav 17]

Wow! Thanks guys this is some wonderful advice!! My BMI has not been close to 40 but for just less than a year because like others I was doing diet pills and weight watchers at the same time.

[t2dav 17]

Okay, now I'm totally worried bc my BMI has waivers from 34-42 over the past two years granted I was taking phentermine and tompax during this time. I wonder if insurance will deny me?