Consultation:

[Monique1123 28]

Hi Everyone,

I've been trying to do some research on Gastric Sleeve and was lucky enough to come across this website. I'm sure there are many other boards that answer this question but I wanted to share my concerns in hopes that I will get a response. I'm set to have my very first consultation with my surgeon this upcoming Thursday and I'm super excited but also very anxious. I have Aetna and I see that there are certain requirements needed in order to be approved. My BMI is currently 38.2. I started my weight loss journey 1,000 times back in November and have only lost 9 Pounds. I have seen that anyone above a BMI of 40 pretty much qualifies for the surgery but anyone between 35-40 needs to meet certain requirements such as High blood pressure or sleep apnea. However, I guess my question is whether they will take my 38.2 BMI along with other side effects due to my weight? Since I've had my son, I've had severe knee pain along with swollen feet. If I stand up in the kitchen simply cooking for too long then my feet will swell up and ache for the remainder of the night along with Severe GERD and IBS. Does the insurance take this into consideration? If your someone like me that has such a high BMI but not at exactly 40, will the doctor try to help, or do they automatically turn you away? I have high anxiety and knowing other's experiences would help me out a lot. I have been trying to lose weight the natural way for years and I'm over it at this point.

Your answers are very helpful.

[JustSJ 57]

I have a BMI of 35 and am scheduled for surgery in June. I'm lucky that my insurance carrier will approve for BMIs of 35-40 with at least two comorbidities.

I definitely don't think the surgeon will turn you away. They should be able to talk you through what your insurance requires and options available to you if your carrier won't cover the costs. My doctor and his staff were very helpful!

[Monique1123 28]

Awesome, I have Aetna and I'm hoping that I qualify. Did they tell you during your first visit whether you qualify or not? I already suffer from anxiety and I've been waiting weeks for this appointment so that just makes it even worse.

[JustSJ 57]

Yes. I had to give them all my info ahead of the first visit and they were ready to discuss it right away!

I had such anxiety about it too. I was worried I would have to justify how I got to this point and explain everything I'd tried over the years. But everyone in the office made me feel comfortable right away and I wasn't embarrassed at all!

[catwoman7 11,216]

it depends on the insurance company. Hopefully you'll get it covered! However, if you have GERD, I'm not sure you want to get the sleeve. Bypass is usually recommended for GERD sufferers, since there's about a 30% chance that the sleeve will make the GERD worse (bypass, on the other hand, often improves GERD - if not outright cures it)

[ShoppGirl 4,905]

My BMI was under 40 and they approved it based on comorbidity of joint pain. But as catwoman7 mentioned you may want to seriously consider bypass if you suffer from GERD. That was one of the first questions the doctor asked me.

[Highly_Undermedicated 55]

It all depends on your insurance and their requirements. But most are the same and still make you follow the same guidelines whether the BMI is 35, 40, 45 or 50. They might approve you easier with a higher BMI but it's still a 6 month long process. My BMI was over 40 and I had to have atleast 2 comorbidities (i had several) such as high blood pressure, high cholesterol, sleep apnea, acid reflux, etc. And you have to see your primary 6 months in a row for weight documentation, visits with a nutritionist/dietician, have a psych evaluation, sleep apnea study (its 2 different nights if you are diagnosed with apnea). EGD. And Some require you to see a Cardiologist. And then a month before your surgery you meet with surgeon again, get surgery scheduled, some require a class or two regarding the surgery, EKG/labs days before, covid test.

Its a 6 month long minimum process. Sometimes longer. Just hang in there. Be patient and go to all of your appointments. Be on time (some docs will mark you as a now show and charge late fees, rescheduling you a month out just for being 10 minutes late).

Good luck on your journey.

[lizonaplane 1,613]

7 hours ago, Highly_Undermedicated said:

It all depends on your insurance and their requirements. But most are the same and still make you follow the same guidelines whether the BMI is 35, 40, 45 or 50. They might approve you easier with a higher BMI but it's still a 6 month long process. My BMI was over 40 and I had to have atleast 2 comorbidities (i had several) such as high blood pressure, high cholesterol, sleep apnea, acid reflux, etc. And you have to see your primary 6 months in a row for weight documentation, visits with a nutritionist/dietician, have a psych evaluation, sleep apnea study (its 2 different nights if you are diagnosed with apnea). EGD. And Some require you to see a Cardiologist. And then a month before your surgery you meet with surgeon again, get surgery scheduled, some require a class or two regarding the surgery, EKG/labs days before, covid test.

Its a 6 month long minimum process. Sometimes longer. Just hang in there. Be patient and go to all of your appointments. Be on time (some docs will mark you as a now show and charge late fees, rescheduling you a month out just for being 10 minutes late).

Good luck on your journey.

This process is not the same for every insurance or every surgery center. I only have four months of monthly nutrition classes, no EGD, no sleep study, no comorbidity requirement since my BMI was over 40 (almost 50 at the start). I have to see my primary care doctor one before the surgery, and I had to meet once with the psychologist and twice with the nutritionist.

My process will be over six months anyway due to COVID delays (a lot of people's surgeries were canceled so I have to wait for them to all have their surgeries first).

[catwoman7 11,216]

8 minutes ago, lizonaplane said:

This process is not the same for every insurance or every surgery center. I only have four months of monthly nutrition classes, no EGD, no sleep study, no comorbidity requirement since my BMI was over 40 (almost 50 at the start). I have to see my primary care doctor one before the surgery, and I had to meet once with the psychologist and twice with the nutritionist.

My process will be over six months anyway due to COVID delays (a lot of people's surgeries were canceled so I have to wait for them to all have their surgeries first).

true. I actually don't know anyone who had to do two nights of a sleep study - although perhaps they might have if the first diagnosis was really bad, and they had to do a second after using a CPAP machine for awhile (to check for improvement?). Not sure - but I don't know of anyone who had to go through it twice.

also, the six-month supervised diet is typically an insurance requirement rather than a surgeon requirement. Not all companies require this - or may not require one this long. I had to do six months - but it could be with either a physician or a registered dietitian.

I didn't have to do an EGD - but I was a bypass patient so maybe that's why. They may have just required it of sleeve patients. I did have to do a nuclear stress test, though, because my surgeon (not my insurance company) required it of patients who were over age 50, or who'd had cardiac issues in the past (I didn't - but I was over 50 years old).

suffice it to say, requirements differ depending on the insurance company and the surgeon. But there will likely be several hoops you need to clear before having surgery.

oh - I did not have to have any co-morbidities since my BMI was over 40. They only required having two or more co-morbidities for patients with a BMI of 35-40. But that was my clinic - I can't speak for every clinic.

Edited May 12, 2021 by catwoman7

[Monique1123 28]

13 hours ago, catwoman7 said:

it depends on the insurance company. Hopefully you'll get it covered! However, if you have GERD, I'm not sure you want to get the sleeve. Bypass is usually recommended for GERD sufferers, since there's about a 30% chance that the sleeve will make the GERD worse (bypass, on the other hand, often improves GERD - if not outright cures it)

Most of my weight concerns happened while I was covered under state insurance- Kaiser who sucked. I was going to the hospital with severe stomach pain and instead of them actually trying to find out what's wrong they diagnosed me with "GERD"/IBS so that I could stop coming to the ER. Since then, I haven't had any GERD-related symptoms but I'll definitely ask the surgeon what he recommends? I've heard many gain the weight back eventually with Bypass but I'm not sure how true that is. I can't wait to find out more information during my appointment tomorrow!!

[lizonaplane 1,613]

11 minutes ago, Monique1123 said:

Most of my weight concerns happened while I was covered under state insurance- Kaiser who sucked. I was going to the hospital with severe stomach pain and instead of them actually trying to find out what's wrong they diagnosed me with "GERD"/IBS so that I could stop coming to the ER. Since then, I haven't had any GERD-related symptoms but I'll definitely ask the surgeon what he recommends? I've heard many gain the weight back eventually with Bypass but I'm not sure how true that is. I can't wait to find out more information during my appointment tomorrow!!

Weight regain is actually more common with sleeve than bypass, but I haven't been able to find exact numbers anywhere. I've seen numbers from 15-30% weight regain for WLS overall, but I don't think most people who regain weight regain all the weight, although I know it does happen.

[Monique1123 28]

9 hours ago, ShoppGirl said:

My BMI was under 40 and they approved it based on comorbidity of joint pain. But as catwoman7 mentioned you may want to seriously consider bypass if you suffer from GERD. That was one of the first questions the doctor asked me.

Right! That's what I was curious about. My insurance does have a list of comorbidities that it must be if your under 40 BMI but joint pain isn't on that list. So I was wondering if that would count or if they were pretty strict on it being HBP/Sleep apnea because I don't think I have any of those. However, I think having swollen knees/ankles should count for something, jeesh!

[Monique1123 28]

1 hour ago, lizonaplane said:

This process is not the same for every insurance or every surgery center. I only have four months of monthly nutrition classes, no EGD, no sleep study, no comorbidity requirement since my BMI was over 40 (almost 50 at the start). I have to see my primary care doctor one before the surgery, and I had to meet once with the psychologist and twice with the nutritionist.

My process will be over six months anyway due to COVID delays (a lot of people's surgeries were canceled so I have to wait for them to all have their surgeries first).

When I called to set up my appointment they told me that my insurance offers a "Fast Track" program which gives me the option of getting the surgery done as fast as I would like. I'm super excited about that! Based on what I read from other people with Aetna you just need 12 nutritionist/dietician visits which you can do once a month - 12 months or once a week which can have your surgery done in 3-4 months!

[Monique1123 28]

Also, Another question.....This is a no-judgment zone... during the months of following this strict diet, I know with Aetna you're not allowed to gain at all so drinking isn't in your best interest. However, I heard you get tested for nicotine and alcohol because they are both a requirement (substance-free). Nicotine is no issue but am I allowed to have an occasional drink over the next couple of months? I'm a little nervous to ask my doctor this during the visit because I don't want him to think that my priorities are not in order.

[lizonaplane 1,613]

4 minutes ago, Monique1123 said:

When I called to set up my appointment they told me that my insurance offers a "Fast Track" program which gives me the option of getting the surgery done as fast as I would like. I'm super excited about that! Based on what I read from other people with Aetna you just need 12 nutritionist/dietician visits which you can do once a month - 12 months or once a week which can have your surgery done in 3-4 months!

I wish I could have done my nutrition classes once a week instead of once a month - I would have paid more for that! Mine are group classes and they are so unhelpful. They don't focus on Bariatric Eating at all, just like "did you know french fries are unhealthy?" On the other hand, I've been able to lost 31 lbs since I started working towards the surgery in January, and I'm really starting to get used to the eating habits I'll need long term, so I am telling myself it's worth it. Anyway, surgeries were stopped until April at the center I'm using due to COVID.