Comorbidities and weight loss approval

[bunnygirl650 16]

Hello, I had the gastric band out in 2017. Because of a dilated esophagus. I hated that because I really did well with it. I wanted to get the sleeve but since my bmi was low the insurance would not approve it , that's what the bariatric coordinator told me . So i went on with life but now it is really hard to get weight off and keep it off i try every day, some times i have slip ups . I am gaining my weight back, so i went to my PCM and she put a referral in for me at the same place i had my lapband put in and removed. The coordinator seem like she really didn't want to help me . I was calling ever couple of days to see if she received the referral. I told her i only had 1 comorbidity hypertension. She said she would speak with the dr to see since he had done my other surgery. He had told me in 2017 to try to keep the weight off, but if i started to gain to come back and see him

I can't even get in cause she says my bmi is only 34 and i only have i comorbiditie.

I have a sleep study on the 24 July to see if I have an apnea. My PCM is really trying to help me. May sound crazy but I hope I do so I can qualify

I am on vacation now and I know I have gained even though I was not trying to but I knew I would. It is so hard. Any one else out there In a similar situation? Sorry for the rambling 😊

[Matt Z 4,139]

2 hours ago, bunnygirl650 said:

I can't even get in cause she says my bmi is only 34 and i only have i comorbiditie.

Your doctor/surgeon isn't who makes this call, it's the insurance company. Don't go off of what they tell you, check with your insurance yourself. I hate to say it, but never just blindly follow what any doctor tells you, if you are able to check and confirm, do so. Be that with another doctor, with your insurance company, etc. I've seen so many instances where a doctor will tell someone something that's wrong, because the doctor knows his/her specialty and that's pretty much it... Call your insurance and ask them what their requirements are and if there are any situations where those requirements are waived or adjusted.

[bunnygirl650 16]

I have contacted the insurance company so may time to find out the qualifications. Its is 35 bmi with a comorbidity. But the Dr office says 2 , as far as approval the insurance company says the Surgeons office and the insurance company is the one that approves you. When I had lapband surgery in 2009 my provider sent the referral to the insurance company I received a approval with in 2 weeks then I went to the surgeon orientation then a visit with the surgeon I had to see a nutritionist and a psychologist no other class that process went so fast. But now the insurance company says I have to attend 6 weekly class that I can call in for because they dont fo the classes within 60 miles from where I live. Have to do a nutritionist, psychologist cardiologist and ekg. So since the Dr office that they contacted out says 2 comorbidities I have to go with that . I have a sleep study scheduled. If it comes back that I do have sleep apnea my dr will submit a new referral I think this time will submit straight to the insurance company.

[bunnygirl650 16]

Will drinking alcohol make you fail a sleep study test

[SummerEssence 130]

On 6/29/2018 at 12:45 PM, bunnygirl650 said:

Hello, I had the gastric band out in 2017. Because of a dilated esophagus. I hated that because I really did well with it. I wanted to get the sleeve but since my bmi was low the insurance would not approve it , that's what the bariatric coordinator told me . So i went on with life but now it is really hard to get weight off and keep it off i try every day, some times i have slip ups . I am gaining my weight back, so i went to my PCM and she put a referral in for me at the same place i had my lapband put in and removed. The coordinator seem like she really didn't want to help me . I was calling ever couple of days to see if she received the referral. I told her i only had 1 comorbidity hypertension. She said she would speak with the dr to see since he had done my other surgery. He had told me in 2017 to try to keep the weight off, but if i started to gain to come back and see him

I can't even get in cause she says my bmi is only 34 and i only have i comorbiditie.

I have a sleep study on the 24 July to see if I have an apnea. My PCM is really trying to help me. May sound crazy but I hope I do so I can qualify

I am on vacation now and I know I have gained even though I was not trying to but I knew I would. It is so hard. Any one else out there In a similar situation? Sorry for the rambling 😊

I get it I had the Orbera Balloon inserted in October 2017 had it in for 6 months lost about 24lbs and as soon as it was out I could look at food and gain weight, at the time I went to get the Orbera Balloon I was 212 at 5"3 and would have probably qualified thru my insurance but, of course my doctor did not tell me anything about any other option not saying it was his fault because honestly I should have did my research to see if that was an option then and when I went back into to see him after the removal, I asked him would I have qualified and he said more then likely but, I had already lost 24 lbs so therefore I wouldn't at the time in April 2017 after the removal I was a bit pissed because the Orbera cost me $8900 self pay and I could have just went with the insurance and gotten the sleeve, I'm currently 198 consider obese but, I don't think the insurance will cover it now because, I do not have any of the illnesses that come with BMI of 35 such as hypertension at least I don't think nor do I have high blood pressure or cholesterol issues, but nonetheless I'm going with a doctor closer to my home because the other doctor that inserted the balloon was 3 hours away going and coming back for a total of 6 hours for a 30 minute appt. I was sick of that drive. I told this new doctors office if I have to be self pay I would pay the $28k she said she would still check with the insurance because there are several other factors. However, I will self pay if need be because, I cannot allow myself to get out of control so many have passed away in my family from weight and various other weight related issues and I don't want that for myself I want to catch this now. So I said all that to say I understand. Its a lot of money but I just thank goodness we have it if need be, but of course if insurance will pay I'd rather use it but, it will not be my deciding factor if the doctor say I can get the surgery, but can't use the insurance. 1st consult is September 4th. I pray they allow me to get it even if the insurance doesn't pay for it.

Edited July 17, 2018 by SummerEssence

[SummerEssence 130]

Edited July 17, 2018 by SummerEssence

[bunnygirl650 16]

Hello, are story is very similar. You should try to get a sleep study to see if you have sleep apnea. I have a in home sleep study this Wednesday. Even though I don't want to have sleep apnea but to be able to qualify for the sleeve is a different story. I have hypertension. Good luck at trying to get your insurance to pay for it. I pray that things will go in my favor .

[SummerEssence 130]

Well, I pray I don't have any issues honestly I don't mind paying I just hope I can get it even if I have to pay. I pray things go well for you too, however you have hypertension isn't that one of the things that is covered and also your BMI is 40.4 I think you will qualify, let me know how things go I pray it works out for you I really do this is expensive, but an expense I'm willing to pay.

[bunnygirl650 16]

I know, that bmi is when I first got my lapband in 2010. I got down to 140 was my lowest but kind of hung out at 158 which I loved now I am back up to 189 a couple of pounds away from 35 bmi . If I could afford to self pay I would also good luck in whatever way you go.

[SummerEssence 130]

Oh ok so your BMI is 35 I see, now I understand. Believe me I’d love to keep the money and insurance pay but, I’m not sure my BMI is enough even being obese. I hope, I pray they say I can self pay even if insurance doesn’t pay.

[bunnygirl650 16]

If you are selfpay I dont see them turning you down .keep me posted

[SummerEssence 130]

5 minutes ago, bunnygirl650 said:

If you are selfpay I dont see them turning you down .keep me posted

I pray they don’t I don’t want to climb back to 212lbs geez. Thanks and I will keep you posted I promise I added a follow you.

[bunnygirl650 16]

When do you have an appointment?

[SummerEssence 130]

September 4th, 2018.

[bunnygirl650 16]

Cool I will keep you in my prayers for approval.