Question About the Whole BMI Thing and Insurance

[Myaiku_Kuraitani 245]

I'm not sure where else to go to ask this because my insurance doesn't give me clear, straight answers (I have UPMC For Life Dual) they said "We don't have access to that information but your doctor does." So I called them and they told me they didn't know, call my insurance.

The question is while you're on the 6 month program and say your BMI gets down to 30-35, can you still get Gastric Bypass? What do they go by? Your current weight at the end of the program or your starting weight? How do they determine that?

I'm sorry if this was asked somewhere else before or if this is in the wrong forum... Feel free to correct me.

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[elisa5150 212]

The bmi is based on your initial visit with surgeon. You qualify multiple times for different things. If he takes you on at first consult you are then given his requirements and your insurance requirements to complete. Surgeon would not put you through process if he can't qualify you. The question to ask your surgeons office is which weigh in do they submit to insurance.

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[Myaiku_Kuraitani 245]

Thanks, I'm not sure why I wasn't told this from the start.

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[boogie_badd8nt_she 43]

I would imagine that you would be able to get gastric bypass if you are healthy..even if you are down to 30 and 35 because you have the ability to choose unless there's a medical reason saying that you can't have one over the other. However I don't know how your insurance work as far as how much weight you can lose.. some want you to actually lose the weight, some want you to demonstrate that you cannot lose the weight,some don't have a requirement I've read..

[lmart133 68]

I do insurance billing and every insurance has their guidelines but one thing that IS a requirement by all is "medical necessity". Your doctor must prove that this surgery is medically necessary regardless of your BMI....hope this helps.

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[Myaiku_Kuraitani 245]

It does. I've been told this by my insurance only it was worded differently.

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[Vinasu 621]

They went by my weight after the three-month weight loss period. I barely scraped by.

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[BettyG 75]

I'm on a 6-month supervised weight loss prior to surgery. I was told that my insurance requires 35+ BMI and that if I start to los e too much, then my dietitian will switch me to a maintenance diet so I don't dip below 35 BMI

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