Opinions wanted :)...Borderline for Surgery w/ Highmark Blue Shield

[twinRN 10]

I am new to the boards...just joined today . I was trolling a little before though. I am borderline to be covered for the Sleeve and I just wanted opinions as to what you think my chances are. Honesty is fine...

So I have had a consult with my surgeon and I was told that Highmark will use my weight at my first nutrition class so my weight at that appt. was 212.5 lbs and my height is 5' 1 1/2" so my BMI is 39.5. Per the medical policy for Highmark it will cover the sleeve with a BMI of 40 OR a BMI of 35-39 with very specific co-morbidities. I'm sure this is not news to most of you, but each insurance company is a little different. The co-morbidities are hypertension, severe sleep apnea, type 2 diabetes, and cardiovascular disease (little vague if you ask me). I do not have any of these specific diagnoses. The annoying thing is I could 100% qualify for a gastric bypass because those co-morbidities are not as specific. I have high tryglycerides (fat in your blood) and low good cholesterol and high bad cholesterol, although my overall cholesterol is just below being high. I also have high fasting blood sugar which my doctor calls "impaired fasting glucose" and I've also heard it called insulin resistance.

Anyway what do you all think? I'm trying to prepare myself that when my surgeon's office submits my packet that I will be denied and have to appeal. I'm hoping I would get approved on appeal.

Thanks for your thoughts or sharing your experiences!

[Jen35 283]

I was in a similar situation. I have Cigna insurance and they require a 3 month pre-op diet which I was doing with my surgeon. My first weight in I was at 39.7 BMI and second at 39.9. My nutritionist said that the insurance should approve as long as the last weight was 40 BMI. So, I made sure that it was Meaining, I ate chinese food the day before (salt=Water retention) and wore my bulkiest clothes. But I don't know if the nutritionist really knows for sure OR if that is true with your insurance.

I also don't have any "qualifying" co-morbidities, but I have RA and fibro, knees pain (pain all over actually) etc. My info was just sent to the insurance for approval on 12/17 so I'm waiting to see. If I'm not approved, the office will automatically appeal. I will also go get a sleep study because I think I have sleep apnea and once that is diagnosed, it shouldn't be a problem getting approved.

[LovetoDeath 93]

I am new to the boards...just joined today . I was trolling a little before though. I am borderline to be covered for the Sleeve and I just wanted opinions as to what you think my chances are. Honesty is fine...

So I have had a consult with my surgeon and I was told that Highmark will use my weight at my first nutrition class so my weight at that appt. was 212.5 lbs and my height is 5' 1 1/2" so my BMI is 39.5. Per the medical policy for Highmark it will cover the sleeve with a BMI of 40 OR a BMI of 35-39 with very specific co-morbidities. I'm sure this is not news to most of you, but each insurance company is a little different. The co-morbidities are hypertension, severe sleep apnea, type 2 diabetes, and cardiovascular disease (little vague if you ask me). I do not have any of these specific diagnoses. The annoying thing is I could 100% qualify for a gastric bypass because those co-morbidities are not as specific. I have high tryglycerides (fat in your blood) and low good cholesterol and high bad cholesterol, although my overall cholesterol is just below being high. I also have high fasting blood sugar which my doctor calls "impaired fasting glucose" and I've also heard it called insulin resistance.

Anyway what do you all think? I'm trying to prepare myself that when my surgeon's office submits my packet that I will be denied and have to appeal. I'm hoping I would get approved on appeal.

Thanks for your thoughts or sharing your experiences!

I am in the same boat. My initial consultation is on Jan.10th. My BMI fell below 40 and I do not have any Co-morbidities. So I am gaining a little weight before the surgery, wearing my thickest clothes and heavy jewelry if I can find it. Hahahhahah

I hate the idea of purposely trying to gain weight but, It's either that or pay 8K out of pocket and fly to Mexico.

[twinRN 10]

Thanks for your thoughts. Actually I'm not sure if Highmark blue shield uses the weight at my first nutrition class of the last? It doesn't says that in the medical policy and when I called Highmark they wouldn't answer specific questions. They just direct me to the medical policy (which I think I know by heart) and the medical policy doesn't say anything about which weight they use. Maybe I'll call the surgeon's office.

Keep it coming...

[Pookeyism 1,143]

Tell the doctor to correct you height to 5" even...or drop a roll of quarters in your pocket.

[lilac lass 34]

My doctor told me they sent in my weight on my first visit. I did have other health issues ( high blood pressure, cholesterol) but my BMI was under 40. The insurance said I had to do 3 month with the nutritionist. Then it was approved. When my surgery was scheduled, my doctor told me NOT to get weighed at the hospital at the pre-op registration because I had lost weight while seeing the nutritionist. He said just tell them you were weighed at my office. I did that and they said well we need to know your weight. So I told them the number from my first visit.

I hope your surgery is covered. Your cholesterol problems might come under heart disease. I mean I got mine approved but then had to have a stress test ( due to my age). I passed that. Yeah it makes no sense but hey it is insurance.

[Jen35 283]

Tell the doctor to correct you height to 5" even...or drop a roll of quarters in your pocket.

Good idea with the quarters:) By my calculations I was at a 40 bmi at the first visit, but they measured me 1/2 inch taller than I thought. The one time I didn't want to be taller! lol

[No game 14,437]

I was almost at a 39 Bmi on my first visit. The doctor told me I might get denied at first because the insurance company needs a 40. Sooooo I went out and ate!! Guess what I was approved the first time. : /

[realign 0]

Wow!

I also have Highmark Blue Shield. In 2011 they started covering the sleeve for patients with a BMI of 50+. They cover RNY and gastric banding with a bmi of 40 or 35 with co-morbidities.

I am looking at surgery this spring and was considering waiting to see if they changed their sleeve policy to cover me. . . I hadn't heard that they had changed it yet, but after reading your post I wonder if they have!

I just called my doctor's office....I hope I hear good news. I would prefer the sleeve as well, but if it comes to paying out of pocket vs insurance, I'll deal with the RNY.