Newbie Here!

[petra1124 33]

Hey Everyone!

I am new to this forum. I was planning on looking into LAP Banding, but after the weigh loss seminar I decided that the sleeve was the best option for me.

I just scheduled my physical exam, nutrition seminar and 1:1 meeting with the nutritionist. I still have yet to even tell my dr about my decision for the weight loss surgery as the last time I brought it up she pretty much told me that I dont need it and that I just need to diet and exercise. I have to schedule an appointment to see her and have the paperwork completed that is required by the surgon, but I did ask at the seminar if my doctor's approval was necessary. He stated that although he likes to work with the PCP, if she is not going to be supportive, then I might want to look into a new doctor or just see the surgon's office for any issues or concerns.

I have my physical exam on Jan 10th, which I am really excited about because I have a lot of questions regardin insurance. I was hoping that I might find some advice on here as well...

My issue is that at the moment I am between 38-40 BMI (my scale broke so Im not quite sure) but I do have high blood pressure. Ive only had HBP for about a year, maybe a little more, and Ive never had a BMI of 40 (maybe when I was 13 and first diagnosed with hypothyroid). My BMI has always been around 35 and sometimes lower, although Ive been overweight since age 11. I am 5'5" and I havent been under 200lbs since I was 21. I am now 30. I am afraid that my health insurance wont apporove me since Ive only had a BMI of 35 or higher and a comorbidity for 1-2 years, but a BMI of 35 or more for 5+ years. Any advice as to whether its a good possibility that I will get approved. My surgon expressed that for his requirements I do not need to have the comorbidity for 5 years, but Im just worried about insurance.

This is what my insurance states (I have Excellus Blue Cross Blue Shield - Simply Blue and I am in Rochester NY):

A: Patients must be morbidly obese, which is defined as either having a BMI greater than or equal to 40 kg/m2 or having a BMI greater than or equal to 35 kg/m2 and existing comorbid condition(s) (e.g., hypertensive cardiovascular disease, coronary heart disease, pulmonary hypoventilation, hypertension, hypercholesterolemia, dyslipidemias, diabetes, sleep apnea, degenerative arthritis of weight-bearing joints, or other weight related arthropathies, and metabolic syndrome). Documentation of the comorbid existing medical condition(s) must be submitted by the primary care physician.

B. The condition of morbid obesity must be of at least 5 years duration.

Hope someone can give me some insight!! I really want this surgery.

[acyclistswife 0]

Welcome! I have bcbs of Massachusetts, though i live in NJ, and had similar requirements to your part A. My BMI was at 40 for the first 2 months of my 3 months, but dropped to 39 on my third month. My insurance coordinator told me that neither high blood sugar, high cholesterol, nor pcos wouldn't count as a comorbidity. I went through a sleep study for sleep apnea, and was dashboard as a result of that study. Based on what you described, you may need something else to be approved, but talk to the person at your surgeons office; he/she should be able to tell you for sure.

[petra1124 33]

I dont have high blood sugar, high cholesterol or PCOS, but I do have high blood pressure and have been on medication for at least a year. I actually was able to weigh myself at work at with clothes on I am 241, which is a BMI of 40 for me. But this is the heaviest Ive ever been. I am usually between 210 and 225.

[acyclistswife 0]

Arrgh-i meant to say high blood pressure not high blood sugar... sorry bout that, i don't have high blood sugar (aside from pcos)

[csmiles 15]

Hello! I have decided to look into VGS as wel. I had my consultation on 12/14. My doctor is really good. I do have some concerns about the procedure. I have been all over youtube looking for answers. I didnt finalize my decision until talking to my cousin. She had the procedure last year.

I am waiting to wrap up a project at work, and loking forward to a surgery date in October. My BMI is 45. I worked for the Blues in Philadelphia, and they are pretty good at approving the procedure if you meet the stated rquirements.

I wish you all the best, and will follow your journey on here. I could use the inspiration.

[petra1124 33]

I'm not really nervous about the surgery... More so the approval process... Im just scared cuz I haven't been at 40 bmi ever... Just 35 or above with Comorbidity.

[Houston17 115]

Hi Petra, I decided on the sleeve after the seminar too. I am waiting to be approved. I am below a Bmi of 40 and have high blood pressure. I got denied in July because I didn't have the 5 year history of the weight. I have only had the high blood pressure a couple years at most. When I got denied, they only said it was because I didn't have the weight history. The way that I'm reading your policy doesn't sound like you have to have the comorbidity for 5 years! Best of luck to both of us!

[petra1124 33]

I've had pre diabetes for the last 5 years I wonder if that counts?

[petra1124 33]

Just reized that I have had metabolic syndrome for the last 5 years as I've been 30> bmi and have increased blood sugar levels although do not have diabetes at this time. So I guess I meet the requirements?! I had to Google metabolic syndrome...

[DreamsOfSkinny 53]

Hi Petra' date=' I decided on the sleeve after the seminar too. I am waiting to be approved. I am below a Bmi of 40 and have high blood pressure. I got denied in July because I didn't have the 5 year history of the weight. I have only had the high blood pressure a couple years at most. When I got denied, they only said it was because I didn't have the weight history. The way that I'm reading your policy doesn't sound like you have to have the comorbidity for 5 years! Best of luck to both of us! [/quote']

Did you ever get approved?

[DreamsOfSkinny 53]

You have to meet your plan's #1 requirement for 5 years. #1 specifically tells you how your ins. Defines morbid obesity so I would call and ask what are all the co-morbidities accepted.

[Ballermom 803]

Welcome

I got Approved my Bmi is 42.8.

First after calling the insurance to see if your plan include it. and if they need a documented weight history. See if you meet the requirements.

Find a Doctor that maybe they recommend.

I ll be switching to one they recommend too because I'm concerned about experienced and good follow up care. My doctor said he never work with a WLS pt, so in switching.

I simply followed the plan they recommended to me. It was the 6 month program not hard at all.

They tried to. Deny me saying my company excluded WLS a last minute trick. I won within 3 hours of finding out about the denial.

You can do it too!

Good luck!

[petra1124 33]

Did you ever get approved?

I am still in the process of going to all of my initial appointments. But as far as my PCP and surgeon are concerned, I meet the criteria that my health insurance is requesting Everything will get submitted once I attend my nutritional seminar, 1:1 nutritionist appt and make an appointment to meet with the surgeon.

[Ballermom 803]

Yes, I got Approved I have Migraine headaches and osteoarthritis.

[Ballermom 803]

Good luck