Damned if you do, damned if you don't?

[FreeTheSkinny66 9]

Howdy! Been lurking on here for a little while and am posting for the first time. I apologize in advance - this is LONG.

I have begun the process with a Bariatric surgeon and am still rather early on in the process. But I am already freaked out and completely terrified of making a misstep, largely because I've read so many things here regarding the different insurance companies and their reasons for approving and denying...and they are ALL DIFFERENT!

Unfortunately (?), I am probably not what would be considered a "clear cut case". My BMI is not quite at 40 (but close), and I do not have any of the normal co-morbidities. In fact, all I really have is joint issues - from a torn meniscus that I had surgery on last May that is STILL giving me trouble, and ankles and feet that hurt (from past sprains and other things, but all exacerbated by me carrying too much damn weight.) I do not have high blood pressure, diabetes or pre-diabetes, sleep apnea (that I am aware of...just sent my at home sleep kit back), high cholesterol, etc - none of it. Despite being obese, these problem have so far alluded me. Key words "so far". There is a history of heart disease (my father died at 66 from a heart attach), high BP and diabetes in my family.

BUT...I do have some things that to me seem to make a compelling case for Insurance to approve me. I was diagnosed with stress or virus induced cardiomyopathy in 2008. It is largely resolved, and my bariatric surgeon poo-poo'd it because it was so long ago. I have a prolapsed mitral valve (but doesn't really cause problems). And I have a myeloproliferative disease that causes my bone marrow to produce too many platelets, predisposing me to blood clots. I've not had any issues to date, and I only take baby aspirin for that now (no prescription meds yet), so not sure how that will be viewed. But if I were the insurance company, I would see that as a damn good reason to help prevent the onset of arteriosclerosis from obesity!

I also have the complexity of having both primary and secondary insurance, so that means I have to meet the requirements of TWO insurance companies if I want both to cover this. (And I do, as my primary insurance is not very good) Primary is Anthem BCBS, and secondary is United Healthcare.

Like everyone else, I've done every diet and exercise program known to man...and been successful. In LOSING, but NEVER maintaining. I always gain it all back, and usually more. Most recently, I did Ideal Protein for 7 months (Jan -Jul 2014) - I was referred by my doctor, and the program itself is run by another doctor. I had to meet with a coach weekly and get weighed and have my fat percentage and hydration percentage measured. I have all those records. I lost 45 lbs (but have gained almost all of it back). But my bariatric surgeon's office said it was too long ago (even though Anthem's guidelines say it must be within the last 2 yrs) and I am going through the 6 months doctor supervised diet with them (the surgeon's office) now.

Now here is where I am freaked out. I am afraid to lose and I am afraid to not lose during this period. I've read that they want to see that you can follow a plan, and therefore want to see weight loss. I have seen people say they lost and were denied because they showed that they really didn't need it because they can lose on their own and their BMI dropped. I've read of people being denied because they failed to make progress (lose) on the supervised diet, or if they gained, showing that they were not serious about lifestyle change. ARGH!!!! I am paralyzed!

I am already concerned that because of my BMI <40 and no "standard" comorbidities that I will be denied. The doctor said I can lose during this time as long as I do not drop below a BMI of 35. And the coordinator who deals with the Insurance said she doesn't think she will have trouble getting me approved. But I am so afraid of making a wrong move. And I do not want to call the insurance company and say something wrong and have them document that soit appears that I am 'gaming' anything, if that makes sense.

I am so stressed out about this. Now that I have decided that this is absolutely the right thing to help me, I would be devastated if I were denied. Am I driving myself batty for no reason? Anyone have Anthem BCBS and a similar situation (BMI < 40 and none of the "standard co-morbidities, but other health issues, such as the joint pain/arthritis?) I could sure use some encouragement.

Thank you all. And reading these forums has been so helpful.

[JamieLogical 8,697]

I didn't go through any of the insurance approval process, since I was ineligible for WLS through my insurance from the very start. I was self-pay. But I have been on these forums for going on two years and I have read a LOT of posts from people going through these things, so here are my thoughts. Take them for what they are worth.

Most insurance companies' cut-offs are a BMI of 40 or 35 with comorbidities. Since you are already below 40, I think your only chance of approval is to make a case for comorbidities. Which means your surgeon is right that you could safely get down to a BMI of 35 during this 6 month supervised diet. The insurance company isn't going to deny you because you dropped from a BMI of 39 down to 36 or 37. If they are going to deny you, it's going to be because your BMI is below 40.

[FreeTheSkinny66 9]

Thank you for responding, JamieLogical. And that does, indeed, seem like a logical view of the situation. Whether the insurance companies will apply logical in this all remains to be seen. lol (and Ive worked in insurance for over 25 yrs! )

Fingers crossed.

[cookarue 233]

How far away are you from 40 BMI? I'm just saying if you had to gain a few to qualify it wouldn't be so bad...

[FreeTheSkinny66 9]

I thought the same thing! lol But they already have my first "weigh in" documented, so that would put me in the "you gained" bucket...getting back to one of my concerns. I am close. Depending on the day (I fluctuate up and down 3 lbs or so) I am usually between about 38-39 BMI. So close!

[diana tx 5]

I am sort of in the same place you are. Lose, gain, lose gain. I am at 35bmi now, so that is even scarier. I have high BP, but that may not be enough. The funny thing is, I went on weight watchers and lost about 28 pounds, but am unable to maintain it. Now I wish I had not lost anything as I would have been almost at 40 bmi.

When I went to my dietitian I told her straight out that if I lost any more weight I would be ineligible. She said that she understood, and that our visits would simply be to nudge me in the right direction of eating better and what and how to eat after my surgery. Needless to say it's bad when I actually have to try and GAIN weight to have the surgery. Insurance companies don't seem to get the whole "I can lose but not maintain" thing...

So now let's add stress for the next 6 months while I see the dietitian and THEN wait to see if my insurance approves me... It's enough to make you want to eat more! ;-P

[FreeTheSkinny66 9]

Exactly! You hit the nail on the head - I can lose, but I can't keep it off. And it is sad that any short term success we have could potentially be our downfall in getting approved. I tend to see the fact that I am able to stick to a program and actually lose (unaided by an awesome tool to make it more manageable to do) as evidence that I am a good candidate! And if I had that extra tool (the sleeve) I might even be able to maintain that loss long term. Unfortunately, I am not sure they see it that way.

I am totally stressed, too! Had I had to laugh at your comment about it making you want to eat. I almost wrote that, too. Stress eating! Glad i am not alone.

Edited March 24, 2016 by FreeTheSkinny66

[InIt2LoseIt 0]

I have a BMI of 40-41 and no comorbidities. I was told not to lose during the supervised weigh in period of 4 mos because I would drop below 40 BMI and could likely be denied. However I'm so worried about getting approved bc my weight in monthly is always while I have my period and my weight fluctuates 5-10 lbs so I'm worried they will claim I gained and deny me. Anyone have any thoughts? Thanks. Good luck all.

Edited March 24, 2016 by InIt2LoseIt