Not going to get approved

[bdaycakegirl 3]

I have been working towards this for 5 months (WL trial) and am ready to meet with surgeon, come to find out, I have to have had a bmi of 40 for five years and proof by doctor record for each of those five years. Well, my bmi has ranged from 38-47, but I have 2 years under 40. So it looks like I will be denied. I have BCBS NJ

[DELETE THIS ACCOUNT! 12,703]

Double check if there is a co-morbidity clause.

Most insurance requires a BMI of 40 or a BMI of 35 with at least 2 co-morbidities. Some possible co-morbidities are sleep apnea, high blood pressure, and diabetes. There are probably others, too.

[bdaycakegirl 3]

Now I just looked up my policy and talked to the insurance company and they said it does not say anywhere anything about 5 years. I also read a 36 page document in regards to gastric surgery in my plan, and it doesn't mention it either. . . I have no idea why my surgeons office would say I need this for insurance, unless this a trick the insurance companies try later?

[GuyMontag 1,264]

Sometimes you just have to keep on trucking and bugging them until they get you approved.

[Sojourner 2,446]

There should be an insurance specialist as a member of the WLS practice office staff. It is their job to know and understand the insurance requirements for major insurance companies.

The insurance specialist at my surgeon's office discovered a specific documentation deficiency in my paperwork before she submitted it. It required an additional letter to address that issue. The result was a first submital approval for me.

Additional co morbidities which are usually accepted by insurance companies for WLS are arthritis, GERD, in addition to sleep apnea, hypertension, and Type II diabetes. The industry standard is either a BMI of 40 or greater, or a BMI of 35 with a significant history of 2 or more weight related co-morbidities. It seems to vary as to the length of time the co-morbidities need to be documented by insurance companies.

[Ddavis5759 9]

Does the insurance cover BMI between 35 and 40?