Help With Bmi Question- Medica

[vanb0052 40]

Hello all! I just attended my first information seminar this week and found that Medica will only allow the gastric sleeve with a BMI of 50 or higher. Currently, depending on when I weigh myself, I'm between 50.2 and 51 BMI.

My Medica insurance kicks in on Jan 1 and I want to hit the ground running to get approvals. I'm scared that if I don't gain some weight that once I go on my pre-op diet I'll lose weight and on the day of the surgery be below 50 BMI and get denied or something.

Any advice?!?

[Sassygirl06 962]

the insurance company goes off of the weight at the first appointment. you are required to lose some weight prior to surgery. I wouldnt lose any weight until you have that first appointment though. good luck to you

[Afro_Cyster 74]

Also, try to get your approval weigh-in during the afternoon as that's when it seems your body starts to retain fluids. It may give you a boost in weight.

[guzel 11]

I have medica too. The insurance coordinator at my dr's office assured me that it's the first weight that medica looks at. My BMI is "only" 43, but they approved me because I also have crohn's. I was approved two days after submitting my paper work so over all I've been quite happy with medica. Hope your journey goes as well! Good luck!

[vanb0052 40]

I'm lucky that I don't have any real complications from my weight yet....PCOS and back pain, but no diabetes, high blood pressure, high cholesterol yet. I just hope it goes smoothly!!!!

Thank you guzel for the information on Medica. Where did you have or are you having your surgery???

I have medica too. The insurance coordinator at my dr's office assured me that it's the first weight that medica looks at. My BMI is "only" 43, but they approved me because I also have crohn's. I was approved two days after submitting my paper work so over all I've been quite happy with medica. Hope your journey goes as well! Good luck!

[guzel 11]

I'm having my surgery on 12/14 at the U of M with Dr Ikramuddin.

[Shellyac 22]

Regardless of your BMI, you should use the following position paper as part of you application to the insurance company. Currently BCBS and probably most other insurance companies use the ASMBS position paper from 2007 as the basis of requiring a BMI of 50. Here is BCBS's statement about the sleeve:

Sleeve gastrectomy has been proposed both as a stand alone gastric restrictive procedure, and as a first stage operation for the extremely morbidly obese patients, e.g. those with body mass index (BMI) exceeding 50, or for those with serious comorbid conditions that would increase risk for morbidity and mortality with the initial use of a malabsorptive procedure such as a gastric bypass with Roux-en-Y anastamosis or duodenal switch. Bariatric specialists believe that with the initial weight loss and improvement of comorbid conditions following the sleeve gastrectomy, the malapsorptive procedure can be performed at a later time if necessary with greater safety. In June of 2007, the American Society for Metabolic and Bariatric Surgery (ASMBS) published a position statement on sleeve gastrectomy as a bariatric procedure. The paper states that sleeve gastrectomy may be an option for carefully selected patients, particularly those who are at high risk or super-obese, and that the concept of staging bariatric surgery may have value as a risk reduction strategy in high-risk patients. The paper also suggests that surgeons performing sleeve gastrectomy prospectively collect and report outcomes data in the scientific literature. Finally, the paper suggests that surgeons performing sleeve gastrectomy inform their patients regarding the lack of published evidence for sustained weight loss beyond 3 years, and provide information regarding alternative procedures with published long-term (>5 years) data confirming sustained weight loss and comorbidity resolution.

However the updated statement that I linked to above, which only came out in October 2011, in summary says

Substantial comparative and long-term data are now published in the peer-reviewed literature demonstrating durable weight loss, improved medical comorbidities, long-term patient satisfaction, and improved quality of life after SG. The ASMBS therefore recognizes SG as an acceptable option as a primary bariatric procedure and as a first stage procedure in high risk patients as part of a planned staged approach. Based on the current published literature, SG has a risk/benefit profile that lies between the laparoscopic adjustable gastric band and the laparoscopic Roux-en-Y gastric bypass. As with any bariatric procedure, long-term weight regain can occur and, in the case of SG, this could be managed effectively with re-intervention. Informed consent for SG used as a primary procedure should be consistent with consent provided for other bariatric procedures and should include the risk of long-term weight gain. Surgeons performing SG are encouraged to continue to prospectively collect and report outcome data in the peer-reviewed scientific literature.

I'm sure that insurance companies haven't had the time to review the new position paper or modify their requirements but I'm sure if you bring it up to them you may have more success in you application.

[vanb0052 40]

Thank you Shelly!

[vanb0052 40]

Shely, the link to the full article did not work.

[Shellyac 22]

Sorry about that. The article should be found at http://asmbs.org/2011/10/statement-update-sleeve-gastrectomy-as-a-bariatric-procedure/

If that doesn't work, go to www.asmbs.org and you should see the headline for the paper about halfway down the page in the middle