Excessive Insurance Requirement?

[byebyebmi 100]

I have started the process of getting the medical clearances for my surgeon's office to send to my insurance for approval. They gave me a packet of general guidelines such as 3 support group meetings, 3 nutrition visits, etc, but advised me to call my insurance company directly to make sure that there wasn't anything extra or different that they required.

So I called Amerihealth today (I live in NJ) and provided them the service code for the sleeve and the representative said that for the sleeve procedure I need to have a BMI of "greater than or equal to 50". That kinda seems excessive to me. The packet I have from my doctors office says: "Greater than 40 or 35 with co-morbidities". Now that being said, I may already meet the requirements (At the present time) if my height is listed at 5'3 then my BMI is 51, if its listed at 5'4 my BMI is 49.88. But I was planning to try to lose 10-20 pounds before my anticipated surgery date in September. That would put me below 50 for sure.

Does anyone else have any experience with Amerihealth or another insurance requiring this? Or does it sound like the rep is nuts?

[gigito2 52]

I don't have any experience with your ins co, but at an informational meeting I went to prior to committing to this, I was advised NOT to try to lose ANY weight prior to my first weigh in with the MD. HTH

[imsoglad56 402]

I'm pretty sure that as long as you meet the requirements and get approved, it's okay to lose weight before the actual surgery. In fact, some surgeons require it.

[byebyebmi 100]

Once I get the approval I definitely plan to lose weight between the approval and the actual surgery date. Multiple people I know have said that once they approve it then its official and they're not going to change everything if you lose 10 pounds.

[gigito2 52]

Right - I didn't mean to infer that you couldn't lose weight pre-op - in fact you will be required to do so. I just meant you shouldn't lose weight before your first visit with the MD where your BMI will be determined. Sorry for the confusion.

[byebyebmi 100]

I had my first visit with them on June 6th, so next time I go in a few weeks i'll have to ask them what they have down. Thats a good idea!

[gigito2 52]

Good Luck!

[no onions 258]

I recommend you get everything in writing. My surgeon's office helped extensively with navigating insurance.

When I called UHC myself, I was told I didn't have any requirements!

When my surgeon's office called they got the real scoop.

[smkallen67 31]

My insurance is being super picky no final approval date and surgery scheduled July 31. I was told to lose before surgery too started at 300 down to 273. Have hospital who does the submitting work their magic. They deal with insurance companies constantly, good luck

Sue

[byebyebmi 100]

I did some extensive searching online and finally found a PDF of Amerihealth's bariatric surgery policy. All of the wording was exactly what the guy said over the phone. BUT...

The BMI of 50 for the sleeve only comes into play if you are getting it as part of a two stage process (like sleeve to bypass or sleeve to duodenal switch). However, as a stand alone procedure it is the standard BMI over 40 or 35 with co-morbidity factors. Looking over the info I can see how he got confused. I guess if they're going to pay for two procedures they want to make sure you are that big to start off.

So the Great Amerihealth Mystery of 2015 has been solved and I'm happy that I can lose some weight and not be disqualified!