Brand Spanking New!

[TAJ718 17]

Hi All, I am brand new. Going to my informational meeting tonight, provided by my insurance company. Health Partners in MN if anyone is familiar. My biggest concern is the requirements:

Weight loss surgery is covered when the member has been evaluated and treated by an in-network designated weight loss surgical physician and all of the following are met:

1. A member must have a documented history of BMI equal to or greater than 40 or a documented history of a BMI greater than 35 with associated health conditions that do not respond to medical management. Associated health conditions for the purpose of this topic are defined as:
   • High blood pressure (BP) of 140/90 or greater, or
   • Dyslipidemia with cholesterol LDL greater than or equal to 130 mg/dl, or
   • Self reported sleep apnea with use of CPAP or other related sleep apnea treatments, or
   • Diabetes with glycosylated hemoglobin level (HbA1c) that is greater than or equal to 7,
   • Pseudotumor cerebri, and
   • These health conditions are not responding to optimal medical management.

I don't have these exactly... but I have some gastrointestinal issues, hernia, ulcer and my esophageal sphincter is wide open, my bmi is 38. I am hoping this will be enough to qualify or meet the requirements.

Anyone have any words of wisdom? Advice? Maybe I'm on the wrong board... lol!?

[Seagull 140]

Hi All, I am brand new. Going to my informational meeting tonight, provided by my insurance company. Health Partners in MN if anyone is familiar. My biggest concern is the requirements:

Weight loss surgery is covered when the member has been evaluated and treated by an in-network designated weight loss surgical physician and all of the following are met:

• A member must have a documented history of BMI equal to or greater than 40 or a documented history of a BMI greater than 35 with associated health conditions that do not respond to medical management. Associated health conditions for the purpose of this topic are defined as:

• High blood pressure (BP) of 140/90 or greater, or
• Dyslipidemia with cholesterol LDL greater than or equal to 130 mg/dl, or
• Self reported sleep apnea with use of CPAP or other related sleep apnea treatments, or
• Diabetes with glycosylated hemoglobin level (HbA1c) that is greater than or equal to 7,
• Pseudotumor cerebri, and
• These health conditions are not responding to optimal medical management.

I don't have these exactly... but I have some gastrointestinal issues, hernia, ulcer and my esophageal sphincter is wide open, my bmi is 38. I am hoping this will be enough to qualify or meet the requirements.

Anyone have any words of wisdom? Advice? Maybe I'm on the wrong board... lol!?

You may have sleep apnea and not know it. At a BMI of 38 you likely do, so I would go for the sleep study

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[James Marusek 5,244]

Many insurance policies are similar in their requirements for eligibility for Bariatric Surgery. According to my insurance policy:

• Surgical treatment of obesity (bariatric surgery) is covered only if:

- eligible enrollee is 18 of age or over

- clinical records support a body mass index of 40 or greater (or 35-40 when there is at least one co-morbidity related to obesity). Applicable co-morbid conditions include the following:

• Type II diabetes mellitus (by American Diabetes Association diagnostic criteria).

• Refractory hypertension (defined as blood pressure of 140 mmHg systolic and or 90 mmHg diastolic) despite medical treatment with maximal dose of three antihypertensive medications.

• Refractory hyperlipidemia (acceptable levels of lipids unachievable with diet and maximum doses of lipid lowering medications).

• Obesity–induced cardiomyopathy.

• Clinically significant obstructive sleep apnea.

• Severe arthopathy of the spine and or weight bearing joints (when obesity prohibits appropriate surgical management of joint dysfunction treatable but for obesity.

So I tend to agree with @Seagull. You may have sleep apnea and not really know it. I did. My wife is a light sleeper and my snoring for years kept her awake at night. This was one of the conditions corrected by my RNY gastric bypass surgery, along with my high blood pressure, diabetes and GERD.

[Djmohr 6,965]

I had my surgery in MN through park Nicollet in St. Louis park. Best thing I ever did for myself. I love their center of excellence and how they prepare you for the transition to a whole new healthy lifestyle. I was so ready by the time I got a surgery date that it honestly was pretty easy for me to give up the crap I used to eat.

I tend to be a rule follower though so I would say I stuck to their plan at about 98% and still do follow most of the rules that were set in place by the team. I would say the one rule that I break everyday is I went back to eating and doing other activities like watching tv or posting on Bariatric pal. LOL. I find when I do that I eat slower and recognize when I need to stop.

If I sit at the table, I find my fork moves faster and before I know it I have eaten more than I should. (I know, backwards right?)

I definately would suggest scheduling a sleep study ASAP. Everyone is right, you likely have sleep apnea and don't know it.

There is an online test for sleep apnea that asks you 7 questions about yourself. It can help you determine that a sleep study is necessary.

That would definately put you clearly in required spot.

[TAJ718 17]

Thank you for the responses! I called right away this morning and talked to my insurance again and it looks like I don't need a referral for a sleep study, so I will be calling to set one up right away. I have reached my deductible and have about $1000 out of pocket left to pay on my plan... so might as well get there. Ugh.

When I call for this appointment, would you all suggest that I mention I am really trying to get the bypass or not mention that? Do you think it could sway one way or the other!? Just want to cover all my bases! Again, Thank you!