Insurance requires morbid obesity for 5 years?

[KaiserKid 81]

Hi all -

I have BCBS-MA. I looked into their bariatric surgery coverage, and I meet all criteria except I have a question about 1 in particular.

It says I need to have documented morbid obesity for 5 years. From my research, that is a BMI of 40 w/ no co-morbidities or 35 with co-morbidities. I have the ability to look at my own medical records at work so I looked into myself.

So the past 5 years my BMI was the following:

Jan 2010 = 39.0

Oct 2011 = 39.2

Oct 2012 = 42.0

Oct 2013 = 38.6

Nov 2014 = 38.4

2015 = not sure why I didn't have an appointment here, so no weight recorded

Jan 2016 = 41.4

This year, I've tried dieting since January when my last weigh-in was, and now my BMI is exactly 40.

I'm nervous because for most of those visits with my PCP, my BMI is under 40. I have no co-morbidities (that qualify - I have hx of depression and insomnia, that's about it). BUT, I was dieting through most of these years. As you can see, it was down, then up, then down, now up again. I'm scared that my insurance won't approve me. I haven't yet had my initial consult, but I am highly interested in gastric sleeve surgery and I just know that there is no way I can lose the weight on my own. I know I will forever swing from BMI of high 30s to low 40s, it's never-ending. I've literally been calorie-counting almost nonstop since 2012. My appointment isn't until late August and I'm doing so much research on this that I'm giving myself anxiety lol.

Anyone else have similar situaiton?

Sorry for TMI, maybe this should have gone into the Emotional Health section lol.

[silverthreads 183]

I wouldn't worry too much. I had the same issue, except that I didn't have many records. Your history shows you close to the line for 5 years so it clearly shows you have struggled with this for a long time--not just recently.

I too had BCBS in another state and since I do have comorbidities was trying to document a 35 BMI. I was approved with the first submission. These things are subjective so even if you are disapproved you have a good shot on appeal.

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[KristenLe 5,979]

@@KaiserKid I think it will be fine - I don't believe BCBS requests records for proof - they just require the surgeon requesting the prior auth to confirm a history of obesity. I would be careful not to go under a 40 BMI if you have no co-morbidities though. Good luck with your journey!

[Amurillo04 109]

I had an issue like that but my coordinator assured me that it just has to show steady weight gain not that you just recently got overweight and decided to get wls.

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[KaiserKid 81]

I wouldn't worry too much. I had the same issue, except that I didn't have many records. Your history shows you close to the line for 5 years so it clearly shows you have struggled with this for a long time--not just recently.

I too had BCBS in another state and since I do have comorbidities was trying to document a 35 BMI. I was approved with the first submission. These things are subjective so even if you are disapproved you have a good shot on appeal.

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Silverthreads - if you don't mind me asking, how much did you end up paying out of pocket? I'm sure it's similar across BCBS.

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[silverthreads 183]

Actually copays very greatly so while I don't mind telling you I don't know it will help. Better to get your full plan brochure (probably a hundred pages or more) and it will tell you.

That said I'm on the federal employees plan and my hospital copay was only $350. Now, I made a huge mistake which cost me a lot so I'll tell you so you can avoid it. When I searched the provider directory there were no bariatric surgeons. My next step should have been to call and ask -- but instead I went to a surgeon someone close to me did--one I knew was well trained, very experienced and also does much more difficult surgeries like liver transplants. I planned to try to get BCBS to cover him and knew I'd have to pay his fees out of pocket if that plan failed. Well--it failed. When my surgery was approved they told me they actually had two local practices under contract--so I could go to those for very little cost but I'd have to get a consult and start the approval process again. I had no desire to start over. I just bit the bullet and paid $6,300 for the surgeon myself. I rationalized it wasn't much more than I would pay in Mexico--my backup plan if I didn't get approval.

So make sure your doctor is in network before you get too far down the road...