Bmi Timing For Use In Coverage Determination

[Raven21 121]

Hello! I have Aetna insurance and I am just about to start my 3 month pre-surgical program. According to the guidelines, BMI over 40 is enough to get approved. BMI over 35 but not 40 requires 2 documented comorbidities. I have them, just haven't gone for the sleep test to officially prove the sleep apnea, haven't been to an ortho to prove the knee problems, etc. I'd rather avoid it if I possibly can.

My BMI is about 40.6, so I should be ok. My question is this, on what day do they consider my BMI to be the ONE they will use? When I start the 3 month program, I would hope I'd lose at least 5 or 10 pounds, if not more. If I do, it will put my BMI at less than 40. I certainly don't want to try NOT to lose weight just to keep my BMI up!

[lovealways 22]

It's hard to determine, because I'm not really sure anyone knows the answer to this. In terms of the supervised diet and losing weight...it's kinda "damned if you do, yet damned if you don't". I would say don't fall below a BMI of 40 for sure...just to be careful

[ALmama 2]

my doctor is submitting my first weigh-in I had at his office which was last week. He is submitting everything to my ins. this week.. fingers crossed.

[Wheetsin 714]

It seems to depend on the insurance co. Mine used the BMI submitted for the consultation prior to submitting for approval. But I've heard of some insurance companies denying people who lost weight during their supervised diet (I never had one) if they'd lost enough weight to fall below the BMI requirements.

[612belly 32]

For me it was the BMi in my first visit!! So check with your doc office!! Good luck!!

[WlsJenny2012 5]

I am in a similar situation. I have Aetna and started my 3 month pre-surgical program on July 5th. My BMI was 39.8 on July 5th and I do not have one of the 4 co-morbidities that Aetna lists (I have an appointment with a sleep apnea doctor on 8/13 to get tested). I am currently at 40 BMI and I plan to stay at this level until we submit for insurance approval at the end of the 3 month period. I am so worried that I will not get approved! I wish you the best of luck!

[Raven21 121]

Jenny, what are the 4 Aetna co-morbidities? I must not have seen that. I start my 3 months next Friday at my nutrition and psych appointment.

Good luck!

[MeMeMEEE 206]

My insurance says weight at the beginning of visits. Call Aetna and ask. It won't hurt!

[Raven21 121]

Seriously?

That would be awesome! I'll call. Thx!

[WlsJenny2012 5]

The 4 co-morbidities are:

• Clinically significant obstructive sleep apnea (i.e., person meets the criteria for treatment of obstructive sleep apnea set forth in CPB 0004 - Obstructive Sleep Apnea in Adults); or
  
• Coronary heart disease; or
  
• Medically refractory hypertension (blood pressure greater than 140 mmHg systolic and/or 90 mmHg diastolic despite concurrent use of 3 anti-hypertensive agents of different classes); or
  
• 
  Type 2 diabetes mellitus
  

Here is a link to the Aetna policy, when I called and talked to a representative, she sent me to this link:

http://www.aetna.com/cpb/medical/data/100_199/0157.html

[IMSKINNY 160]

The 4 co-morbidities are:

[*]Clinically significant obstructive sleep apnea (i.e.' date=' person meets the criteria for treatment of obstructive sleep apnea set forth in CPB 0004 - Obstructive Sleep Apnea in Adults); or

[*]Coronary heart disease; or

[*]Medically refractory hypertension (blood pressure greater than 140 mmHg systolic and/or 90 mmHg diastolic despite concurrent use of 3 anti-hypertensive agents of different classes); or

[*]

Type 2 diabetes mellitus

Here is a link to the Aetna policy, when I called and talked to a representative, she sent me to this link:

http://www.aetna.com/cpb/medical/data/100_199/0157.html

I didn't have Aetna, but was told my ins used the Aetna criteria. I think that if you have a 40 or above BMI, co-morbidities are not required, but certainly help. Believe me, if you go through the battery of tests, they'll find something. I didn't know I had sleep apnea or GERD until this process began. I was approved on July 3 and my surgery is Aug 16. It will work out for you.

[JonathanS 75]

I'm with you IMSKINNY. The surgeon already requires a lot of testing just to have the surgery. I would be surprised if they don't require you to have the sleep study anyway.

[Red_Charms09 102]

I have Aetna and was told by my doctor I had to be monitored for 6 mths and do exams. Just found out I have severe sleep apnea, I did a at home study because Aetna denied sleep study at the clinic.

[Need-a-Sleeve 211]

I work for one of the carriers & was told they went by the BMI submitted by the physician requesting the pre-determination for the procedure.

When my BMI hit 40, I went to get medical clearance by my PCP & then to the surgeon. It was 40 the day I weighed in at the surgeon & that is what they went with--in the meantime, I am on the pre-op diet (my own choice as it didn't seem right for me to make the decision to change & then gorge).

Still waiting for the approval but have lost 7 pounds in 5 days, so that helps me!

[WlsJenny2012 5]

I just visited my surgeon's office this past week and they will be submitting the weight they took this week to insurance. I still have to get my sleep apnea test (8/30) and stress test (have an appt with my PCP on 9/6 for a referral). It is now my understanding that any weight loss between now and insurance submission will NOT impact the decision. This is such a relief, I can start incorporating many of the changes I know I will have to make!