Insurance questions (regarding BMI/weight loss)

[ohclementine 9]

Quick question for anyone who might know: My insurance has a BMI requirement of 50 in order to meet approval for the DS surgery. I was at 50.5 at my first doctor visit and actually gained about 10 pounds because I was so afraid of dropping below 50. My question basically has two parts:

1) If I were to begin at 50.5 and then drop down below 50, would I automatically be disqualified? My surgeon's office seemed to almost be telling me to maintain my weight and not lose any and that it would not affect insurance approval if I did not lose weight.

Which brings me to:

2) My insurance requires a 3 month doctor assisted "weight loss" program prior to surgery. January is my 3rd month and I'm honestly postponing the appointment until I get some feedback on this post! Will not losing (even gaining) weight during the doctor assisted weight loss negatively affect insurance approval? Again, my surgeon's office did not seem to think so but I'm wondering if anyone has any personal experience with this? If there's anything I need to do differently, I would love to know before my final appointment.

And, of course, I realize this all varies from insurance company to insurance company. I'm just hoping to get a general idea of what to expect. I guess I'm getting nervous being so close! My surgeon's office keeps assuring me that my wonderful surgeon will do a peer-to-peer with insurance if necessary, but I would like to be as proactive as possible on my end too.

Thank you in advance for any replies!

[MrsB2007 90]

Question 1--people say ins goes off starting BMI to qualify.. However if you lose too much they think you can do it without surgery.

Question 2...i would be careful putting off 3rd visit..dont let it go too far because you may have to start 3 months all over..and usually unless your ins specifically says you need to show weight loss i wouldnt worry..i would however worry about weight gain as many have been denied for even gaining 1lb.

[Susanjoyce392 66]

I have BCBS insurance. I had to have BMI of 35 with co-morbidities (PCOS and sleep apnea). I think I was at 36.7 when I qualified and I was at 34 on the day of surgery with no issues. This was for sleeve surgery, but same concept. I felt reassured after sitting down with the woman at my surgeon's office who submits claims. She was adamant that my initial qualifying BMI would be used. It does seem as different insurance companies have different policies, so you should also check with your specific policy for reassurance. Good luck!

[sarah-tiffany 10]

I have BCBS of MI, and I too am hoping for the DS. The way it is working for me is probably different b/c I am not required to do the 6 month wait b/c my bmi is more than 50. Anyways, the way it works through my surgeon & insurance is they take your very FIRST WEIGH-IN. That is the # they go by. I still have to get weighed for any and all visits, but my initial weight is only submitted once to insurance. All insurances are different, but I would think that your WLS coordinator would have the answer for you. That's where I turn to for all of my insurance questions. Good luck!

[MrsB2007 90]

Yes.. Trust the coordinator.. They do this a lot! They know what is expected and what would disqualify you.

[shellyq 0]

I was in the same exact situation. On the borderline of the BMI so that Cigna would pay surgey, was also required to do a three month supervised diet. During the three months supervised diet I actually gained ten pounds due to having foot surgery and being laid up for over a month and then trying to compensate by not having enough calories. Cigna required me to do an additional three months basically saying that if I couldn't stick to a doctor's diet for three months then I wasn't serious enough about losing weight to have surgery. During those extra three months I lost the ten pounds and an additional seven pounds putting me right at a BMI of 50. I would think that your surgeons office has seen plenty of these scenarios and can guide you on the right path. Personally, I would take the supervised diet seriously and try to lose a few pounds so the insurance company can see how important this is to you but also be careful to not go gung ho. Good luck and I'm hoping all goes well.

Edited January 6, 2015 by shellyq

[blondiebabs 214]

I had to have a 6 month diet, and two of the weigh-ins I actually had a gain, both times I told him was super bloated (I was) and my dr noted it, and my insurance didn't seem to count it against me because they approved me.

[Jersrose43 837]

If you have aetna and have a net gain from start to finish you can guarantee a denial.

[Marie Louise Hoefer 3]

I have Aetna and for me it was what ever weight I started at I couldn't go over by the time I weighed in on my third visit after the initial consult. I went in for my first consult on 5/23, my last visit during the 90 day pre-op period was 8/23, so basically I had four months, but technically 3.. I dunno... I had gained like 10 lbs between June and July's dr visits, but was able to drop from 415 to 394 on my last pre-op visit, then on my surgery day on 9/22 I weighed in at 385. So I would assume that as long as you don't go over the starting BMI and you don't loose too much BMI you'll be ok.

[snarkychef 4]

I have Blue Cross, and I had a switch done with a BMI of 35.9. I'm very lucky in that my doctor is the head of the bariatric fellowship department at a big teaching hospital, and he basically set the Blue Cross standards. He even got any kind of pre-op dieting waived. You just have to meet with their dietician twice a month while going through all of you pre-op testing. I was turned down, but I actually went to the Blue Cross office and sat in the lobby until someone from appeals came down to see me and I asked her to schedule a peer to peer confernce with my doctor. It took me staging a sort of sit in, but they scheduled the call and I was approved the next day. Talk to your doctor about qualifying co-morbidities. If he can tell them why he thinks the switch is the best operation for you, you can likely get it approved at any BMI.