BSBC MA - BMI 40 and afraid I will not be approved

[pato_3472 6]

Hi

I am just starting this WL journey and I am already stressed about my insurance. I have Blue Cross Blue Shield Massachusetts and my BMI is 40 with no medical problems, which is the minimum necessary for them to approve my gastric sleeve surgery. The insurance person from my WL center does not want me to loose more than 5lbs as she is afraid if I loose too much the insurance will then say I am doing great on my own and do not need the surgery. She thinks I am in a tricky situation because if I do not loose it will count against me but if I loose too much it will also go against me.

I was wondering if anyone out there has been or is in a similar situation and was the outcome? I really do not want to get my hopes high on being able to get surgery and then get denied by my insurance. Thank you so much for any help and or advice!

Patricia

[darby0375 18]

I'm in the same boat, other than I do have comorbidities in addition to a BMI of 40. I have to do a 6 month physician-supervised weight loss attempt...and part of me is afraid to lose too much. I guess if that was a realistic fear for me to have I wouldn't be to the point of needing surgery. I meet with my surgeon for the first time in 3 weeks and I'm sure I'll learn more then, but in the mean time I'm about to drive myself crazy with all the reading and research to learn more lol.

I wish you all the best! Hopefully someone here can give us some guidance to ease our minds.

[finediva 979]

@pato_3472. Just to be clear, does your insurance require you to lose before you are approved?

[pato_3472 6]

In it's requirements it does not say so. It says the following:

Patient Selection Criteria

Adults over the age of 18 or who have documented complete bone growth are eligible for obesity surgery

if ALL of the following criteria are met:

 The physician has indicated that the patient:

o Is a well informed and motivated patient with acceptable operative risks, AND

o Has a strong desire for substantial weight loss, AND

o Has failed other non-surgical approaches to long-term weight loss, AND

o Is enrolled in a program which provides pre-op and post-op multidisciplinary evaluation and care

including: behavioral health, nutrition, and medical management AND

 The patient is morbidly obese with a BMI > 40kg/m².

But it seems that my WLC, Lowell General Hospital in Ma, wants patients to loose 5% of their weight before surgery.

@pato_3472. Just to be clear, does your insurance require you to lose before you are approved?

[pato_3472 6]

In it's requirements it does not say so. It says the following:

Patient Selection Criteria

Adults over the age of 18 or who have documented complete bone growth are eligible for obesity surgery

if ALL of the following criteria are met:

 The physician has indicated that the patient:

o Is a well informed and motivated patient with acceptable operative risks, AND

o Has a strong desire for substantial weight loss, AND

o Has failed other non-surgical approaches to long-term weight loss, AND

o Is enrolled in a program which provides pre-op and post-op multidisciplinary evaluation and care

including: behavioral health, nutrition, and medical management AND

 The patient is morbidly obese with a BMI > 40kg/m².

But it seems that my WLC, Lowell General Hospital in Ma, wants patients to loose 5% of their weight before surgery.

[pato_3472 6]

I'm in the same boat, other than I do have comorbidities in addition to a BMI of 40. I have to do a 6 month physician-supervised weight loss attempt...and part of me is afraid to lose too much. I guess if that was a realistic fear for me to have I wouldn't be to the point of needing surgery. I meet with my surgeon for the first time in 3 weeks and I'm sure I'll learn more then, but in the mean time I'm about to drive myself crazy with all the reading and research to learn more lol.

I wish you all the best! Hopefully someone here can give us some guidance to ease our minds.

I completely understand you! I do not want to go through all the process, spend money and get my hopes high if most probably I will be denied. When you read the different blogs so many people have been denied with a higher BMI than mine that is quite scary. I have to say the whole insurance thing is scary. I am also trying to figure out how much will I finish paying out of pocket and even that is confusing....

Best of luck to you too!

[EvieLamp 11]

I have a different insurance carrier but I had the same concern. I'm currently at 41.5 bmi and I brought up my concern of falling below 40 at my 2nd weigh in with my nutritionist and she said it didn't matter how much i lost they go by the very first weigh in at the start of the supervised diet.

[pato_3472 6]

I have a different insurance carrier but I had the same concern. I'm currently at 41.5 bmi and I brought up my concern of falling below 40 at my 2nd weigh in with my nutritionist and she said it didn't matter how much i lost they go by the very first weigh in at the start of the supervised diet.

Hi EvieLamp

If that is the case that would be great! I am glad your insurance is like that, however mine might not be. The insurance expert of the WLC was a bit concerned and even said BCBS MA could be tricky while other insurance companies were a lot more straight forward. This WLC is in a very important hospital in the area, Lowell General Hospital and I am sure they have done hundreds of these procedures and probably dealt with my insurance many times.

I am just going to follow what they say and keep my fingers crossed

Good luck!

[FOXYLADYA 4]

I am in the same situation. I attend my first meeting next week. I have Cigna open access. My Bmi is just 40. I recently have had a A1C level of 6.9 usually Im 6.2 or so. I have been overweight all my life. After Yo Yo dieting in recent years I decided that I needed real help. I'm afraid since my Bmi only reached 40 in the last month and I dont have official diabetes or high blood pressure or anything else associated I may get denied. Has anyone else had Cigna and just reach 40 for a BMI with no other significant (according to them) issues? My Cigna is from New York.

[Aranks 94]

I have BCBS for hospital and United for all other health related schpeel from NY. I had a BMI of 40 with no comorbidities and when I asked my surgeon about what happens if I drop below from losing any weight, being I was directed to lose 5-10lbs, I was told it goes from when I started the process not what my final weight is. Hope the same is for you!

[piaffe3 6]

I am in the same boat. I had to do the 6 month of doc visits (BCBS Federal) to discuss weight loss. I am at month 5 of this fun and hovering between 40 and 41 BMI. I have lost 20 lbs and I am so frustrated that this stupid number could prevent me from qualifying for this surgery. I've been told by my primary not to lose more. I did get recently diagnosed with sleep apnea so I don't know if that will be a factor or not.

I've struggled with weight loss and always end back up at the same 240-250lbs range over the past 14 years. I am so ready for a change!

That's my rant! Hoping BCBS will approve me in late January.

[amazon 579]

I also have BCBS-MA. I just qualified at the beginning, I think my BMI was 36 (224 lbs)and I had a co-morbidity (they required one)

I went through Lahey Hospital, Burlington. I was told I could lose as much weight as I wanted prior to surgery - that BCBS-MA went by the weight from the first visit. My surgeon said to try to get to 200lbs., that it would make the procedure easier.

Also, the NP told me that BCBS-MA was the easiest of them to work with. It actually relaxed my mind a bit, allowing me to focus on ME through the process, and not worrying about insurance.

I was 195 (well under BMI 35) the day of surgery, and there were no issues with coverage.

I would suggest that you contact BCBS-MA directly and ask the question. I don't know how you can go through the pre-op program, including shrinking your liver, without dropping weight before surgery...

Best of luck!

[pato_3472 6]

I am in the same boat. I had to do the 6 month of doc visits (BCBS Federal) to discuss weight loss. I am at month 5 of this fun and hovering between 40 and 41 BMI. I have lost 20 lbs and I am so frustrated that this stupid number could prevent me from qualifying for this surgery. I've been told by my primary not to lose more. I did get recently diagnosed with sleep apnea so I don't know if that will be a factor or not.

I've struggled with weight loss and always end back up at the same 240-250lbs range over the past 14 years. I am so ready for a change!

That's my rant! Hoping BCBS will approve me in late January.

I totally understand your frustration. Best of luck!

[Tamster01 36]

Hi

I am just starting this WL journey and I am already stressed about my insurance. I have Blue Cross Blue Shield Massachusetts and my BMI is 40 with no medical problems, which is the minimum necessary for them to approve my gastric sleeve surgery. The insurance person from my WL center does not want me to loose more than 5lbs as she is afraid if I loose too much the insurance will then say I am doing great on my own and do not need the surgery. She thinks I am in a tricky situation because if I do not loose it will count against me but if I loose too much it will also go against me.

I was wondering if anyone out there has been or is in a similar situation and was the outcome? I really do not want to get my hopes high on being able to get surgery and then get denied by my insurance. Thank you so much for any help and or advice!

Patricia

I have BCBS of Massachusetts and didn't have a problem at all getting approved. I started the process on September 11th and my surgery was done on December 2nd. BCBS does not required a waiting period but you do have to show you have tried to lose weight. My surgeon required a lot of test to be done and I mean a lot of test.