How hard is it to qualify for surgery?

[RollingRing 3]

I am just starting the process of possible surgery and am very nervous that I won't get approved. I have recently diagnosed HBP, high cholesterol, and prediabetes. My BMI is 41. I know it all depends on insurance (I have BCBS MN). How hard was it to get approved and does a surgeon have the final say really?

[liannatx 897]

I would think that your BMI along with the Co-morbidities would get you qualified easily, I don't know anything about BCBS MN though. Maybe someone with the same insurance, or knowledge or it, can give more input.

[BLERDgirl 6,417]

It really depends on insurance & BMI. Typically over 40 BMI will qualify. Depending on your medical history you may or may not be required to undergo a medically supervised diet anywhere from 3 mths to a year before being approved. Having comorbs helps with the approval process.

[Stephanie Stroup McIntosh 157]

Your surgeon's office should know what you need for insurance approval. BMI over 40 typically leads to approval assuming you do what they tell you to do. The process for most insurance companies is about 6 months. Do what they tell you and research a lot so that you are ready when they schedule you.

[BLERDgirl 6,417]

Your surgeon's office should know what you need for insurance approval. BMI over 40 typically leads to approval assuming you do what they tell you to do. The process for most insurance companies is about 6 months. Do what they tell you and research a lot so that you are ready when they schedule you.

It can be as short as 3 mths. Mine was 4mths from the time I had my first appointment with the surgeon and I took a month off for family events. I attended a seminar at the end of April, Surgeon's appointment in May. Surgery in September. Over 40 BMI, no comorbities unless you count pre-diabetes. No pre-op diet.

[CTDEE 58]

First it depends on the plan your insurer selected. I work for one of the largest insurance companies and it's not covered for us under any circumstance though we cover it for most other companies. My husband's company covers it 100%. When I started they only required either a BMI of 40 or greater with no co-morbidities or 35 with at least one co-morbidity. At the time they only required 1 NUT visit but that changed as of Jan 1.

If your company does not specifically exclude WLS you should be fine.

Edited April 6, 2015 by CTDEE

[Bandista 7,466]

Call your insurance company and find out exactly what they cover. My insurance had only one requirement -- a BMI of 40+. They do not account for co-morbidities like high blood pressure, sleep apnea, etc., but most of them do. I was so worried about which weigh-in number would be used, etc., as I was borderline. I made sure I weighed in heavy just in case (they don't ask you to empty your pockets).

[CTDEE 58]

Right. Before approval they always told me to leave my shoes on. Lol

[NikkiDoc 312]

Call your insurance company each one is different. I have Horizon BC/BS NJ. I would have needed BMI of 35 and co-mobidity or 40 + BMI no co-morbidities. I had to show proof of a supervised diet in the last 2 years through my PCP, weight watchers, Medi-fast. Since I did not have that I needed a 6 month supervised diet. I did it through my PCP office as a combination PCP and nutritionist. I needed 1 psych visit.

Additionally my surgeon required lab work, an upper GI, H Pylori test. If I had any symptoms or was heavier I would have had to have a sleep study. The other doctor in the practice requires all his patients to see a pulmonary doctor to evaluate for sleep apnea and if the pulmonogist recommends it then a sleep study.

Once the surgeon's office sent the proof of the 6 month diet and the psych eval in it was approved quickly. Sent on Tues and approved on Thursday afternoon.