BMI and insurance approval

[nicksmommy 139]

Hi there. I was banded in Oct. 2008, had a slippage/repair in August 2013, and am now looking for a sleeve conversion. I lost about 50# with the band over the last 7yrs (lost, gained back, lost again.... you know the routine). I have gained all but 13# back. Today was the first appointment with my surgeons office to get the process started. They unfilled my band and said I have to do the 6 months of appointments/supervision before I can set my date. I go for a. Upper GI tomorrow to check for another possible slippage as I have been having horrendous reflux issues. Today, my BMI was at 40. I do not have co-morbidities to do the 35 BMI approval. My concern is that with ANY weight loss in the next 6 months will put me under the 40. Does the insurance approval go by my starting BMI of 40, that I am today, or whatever I end up with if I lose weight at the end of the 6 months?

[2goldengirl 2,076]

Contact your health plan and request a copy of their criteria for revision of bariatric surgery - this is key, because most health plans have different criteria for revision than initial surgery.

Hope this helps!

[nicksmommy 139]

Thanks. They did email me a copy of it all, and it says BMI of 40 or above, or 35 with co-morbidities. I'm hoping they go with the BMI of the initial appointment of the process.

[sassyfrass23 525]

I've yet to figure this out for myself! Every time I called insurance, I either received conflicting information or they acted like it was the strangest question they'd heard???? When I I initially began the process, I was a BMI of 40 point something. And then my Dr wanted to put me on an appetite suppresent, which I took and lost enough weight the following month to drop me below the 40 mark. I mean BARELY below. By the next month, I was back up, unintentionally. The meds wore off and lost their effect. I have worried sick over that drop but keep reading that some say they look at initial BMI, ending BMI or BMI of each month. I've yet to figure it out. So...I guess I'll find out the true answer when papers are submitted at the end of this month I really do wish they made their stipulations more clear..

Good luck!

[nicksmommy 139]

Thank you! I know in the next 6 months they will expect me to lose some weight, but that won't be a good thing IF it keeps me from getting the final approval!! Ughhhh!! Good luck to you too! ????

[sassyfrass23 525]

It's a sick game they play! Sure- I can shed a few pounds but maintaining that weight loss is another story. January 2015, I began eating clean. Cut out all sugars, processed foods, red meat, etc. Basically everything I ate was organic and as healthy as possible. Cut out diet coke and drank only Water. Also implemented 30-45 minutes/day on the elliptical. After 3 months, I had only lost maybe a total of 8 lbs. During that time, I would lose a pound or two, and the next morning be up 4 pounds. No joke. By June I had lost all hope and made an appt with my PCP to see what he could suggest. Which is where the appetite suppresent came in play. My first 3 months of my weight loss attempt were done without any intention of surgery. I hadn't even considered it. Until my 3 month when my weight came back, and my PCP reviewed my diet/excercise journal. He then mentioned surgery so I checked into my insurance plan and found that it was covered if deemed medically necessary.

I alone, can lose the handful of pounds my surgeon requests prior to surgery. Which will allow me to be physically equipped to handle the procedure. But if I lose the weight, and I am punished for it because I literally drop to a BMI of 39.6....how does that make sense?

With your BMI...you literally HAVE to maintain your weight! That's cruel. Have you met with a nutritionist to discuss what/how you should eat to keep you at your weight?

[860971 31]

Hello. My surgery is on 01/14/16. I too have been lugging around my "get me to bariatric surgery backpack" literally 20-25 pounds of test results,food logs, seminar papers and everything possible to prove I am in need of the procedure for over 14 years. I came close 3 times however two times I had to care for my ailing parents which both passed. The third was having to have an emergency surgery. My MD suggested waiting 6 months for another surgery since the last one was hard on my body. Once ready the insurance said all pre approval appts and attempts had to be in the last 6 months. I was stuck in a catch22. I had a hard time finding a surgeon that I liked and was comfortable with. Once I found him another roadblock, he came down with a neurological problem and stopped practicing the day he found out. The other problem for me was my weight varied from a BMI of 41.0 to 39.8 when starting the program only to have my BMI go close to 38 and be told I lost "too much weight". I finally found a doctor who said that is a bunch of BS. That is the sole reason most people need the surgery. Most can lose some weight but most gain that back plus more. After calling the insurance to let them know my trials and failures and that the bariatric team wanted me to repeat the program again she was upset. She said that the insurance could have covered the surgery twice over. She called the team and within the hour I had a surgery date. I stood frozen, scared, excited and hopefull.

[nicksmommy 139]

With your BMI...you literally HAVE to maintain your weight! That's cruel. Have you met with a nutritionist to discuss what/how you should eat to keep you at your weight?

Yes!! I don't want to gain, but now afraid that I might even gain since I got a complete unfill of my band yesterday. Yesterday was also the start of my 6 months of appointments for my sleeve conversion. My surgeons office sent me for an upper GI (done this morning) to see if there was a problem with my band and causing the horrible nighttime reflux. If there was a problem, then my conversion would possibly be sooner, if the band needs to be removed and I could do both surgeries done in one shot. But the feeling I got from the radiologist today was that the band is fine. Good, but not good..... ughhh. I have a call in to the weight control center to schedule my first appointment there with the dr/nutritionist.

[nicksmommy 139]

Hello. My surgery is on 01/14/16.

Yay!!! Congrats to you FINALLY getting your surgery date! Sounds like it was a long, winding road, but you are there! They definitely don't make it easy for us, do they?? Sounds like your new Dr. is a keeper!!

Edited January 7, 2016 by nicksmommy

[sassyfrass23 525]

@@860971 thank you so much for sharing! I am truly praying that I will not suffer for dropping below the BMI of 40 for one SHORT month. I gave it my all. I tried to lose the weight and do what insurance had asked. It worked but thr weight came back as usual. One plus was that I didn't gain a couple of extra pounds like I usually do. So although that attempt can be deemed as another failure, I at least stopped the cycle of gaining additional weight after dieting.

I hope that if, God forbid, they do deny...my surgeon will do a peer to peer and stress the importance of this surgery in relation to my family medical history. Heart disease/attacks have occurred in EVERY one of my daddy's siblings (6) including him who had 3 himself. His final one requiring 5 bypasses. The same situation on my mama's side. I don't have the mindset of "IF" my heart gives me trouble...it's WHEN my heart gives me trouble. Genetics play a huge role and my way of preventing that is to get myself at a healthy weight to remove the stress from my heart. And a good number of those relatives have healthy weights and still suffered from issues. I'm just doubling my chances at this point.

Edited January 7, 2016 by sassyfrass23

[sassyfrass23 525]

@@nicksmommy if there was an issue with the band, were you going to be able to bypass the 6 month requirement? I hate to hear the situation you are in. IF the band was working even partially, it is unrealistic for them to expect you to maintain your weight or lose any without its help. I mean afterall...you did have it placed to assist with weight loss. I made a mistake of avoiding the scale last month and rolled up in my surgeon's office after gaining 2 pounds. However- it was the end of the day, I'd had a late lunch and literally ate an hour before my apt and had been on my period for 2 weeks. Now I am weighing myself daily to stay on top of it and will hopefully be down those 2 pounds plus 1 more by the 20th which is my next appointment. I'm not worried about the gain because their scale is 2 lbs less than my PCP. So on the chart, my numbers looked the same and showed no influx if compared.

[nicksmommy 139]

@@nicksmommy if there was an issue with the band, were you going to be able to bypass the 6 month requirement?

I believe if it had slipped again, they would be able to do it all in one surgery without having to do the 6 month wait. I could be wrong, but I think I've seen other cases on here that have been like that. Got my results back... no slippage. So now to get the 6 month thing started. You think with all of your immediate family medical problems, that would be acceptable for the insurance qualifications.

[sassyfrass23 525]

@@nicksmommy if there was an issue with the band, were you going to be able to bypass the 6 month requirement?

I believe if it had slipped again, they would be able to do it all in one surgery without having to do the 6 month wait. I could be wrong, but I think I've seen other cases on here that have been like that. Got my results back... no slippage. So now to get the 6 month thing started. You think with all of your immediate family medical problems, that would be acceptable for the insurance qualifications.

One would think, huh?? Lol

Well I hate to hear the "bad" good news. However, I will be rooting for you over these next 6 months! They'll be over before you know it!! You're welcome to contact me should you want to chat....SCREAM....whatever you feel!

[nicksmommy 139]

@@nicksmommy if there was an issue with the band, were you going to be able to bypass the 6 month requirement?

I believe if it had slipped again, they would be able to do it all in one surgery without having to do the 6 month wait. I could be wrong, but I think I've seen other cases on here that have been like that. Got my results back... no slippage. So now to get the 6 month thing started. You think with all of your immediate family medical problems, that would be acceptable for the insurance qualifications.

One would think, huh?? Lol

Well I hate to hear the "bad" good news. However, I will be rooting for you over these next 6 months! They'll be over before you know it!! You're welcome to contact me should you want to chat....SCREAM....whatever you feel!

Thank you! I'm bummed about the wait, but it'll be over soon enough! I hope yours comes up quickly too! Keep me posted on your progress too or if you need to rant!!

[RileyBear 1]

I am a medical review nurse for insurance companies. I did all the leg work for approval for the sleeve. My BMI is 38% however I am on HCTZ for BP and on a medications for GERD and depression. I first called the insurance company for a copy of the medical policy.I have Arkansas BCBS. The policy requirments are

• • Patients with morbid obesity with a Body Mass Index (BMI) greater than or equal to 40; AND
  • Have failed a structured weight loss program; AND
  • Are well-motivated and understand the risks of the surgery and the restricted eating habits which follow the gastric restrictive or bypass surgery; AND
  • Are over the age of 20.

Body Mass Index of 36 – 39

Patients with Body Mass Index of 36 - 39 may be considered for coverage if they meet the other criteria above, and have high-risk co-morbid conditions (e.g., uncontrolled diabetes mellitus, uncontrolled obstructive sleep apnea as defined in the sleep apnea policy, uncontrolled hypertension, uncontrolled hyperlipidemia)

I then wrote a 4 page letter outlining my past attempts at weight loss, family history and statistics with references. I faxed it to the pre-auth team with directions to have review by the medical director....I called my PCPs office and had them fax my last 5 years of records. I called insurance company and verified the information was received. I then faxed my letter for pre-approval. I called every day for status up dates and within 2 days I was approved. SO please do your due diligence. Don't only rely on your physician but become your own advocate!