Determining overweight percentage for insurance.

[Mattie 0]

If my insurance says I have to be 100% over what should be my normal weight, PLUS comorbidities, BUT if I'm 200% over what should be my normal weight I don't have to go through the comorbidities workup, how do I know which catagory I fit in?

I just don't want to waste a couple of extra months having to go through another sleep apnea test (which I have), diabetes (I have Type II and take medication for it but it's under control and has been for 10 months), more painful fibromyalgia testing (have been on permanent disability for it for 10 years), more CT scans for my degenerative arthritis in my spine, etc.

I mean really, I need this. I'm going to die if I don't have this. Why make me suffer needlessly just to prove what is already medically documented and quite obvious even if they only open their eyes partially and look at me!

I'm 5 ft tall and weigh 350 pounds (gulp). I'm ready. I go to my pre-op seminar on April 10th. I have Medicare as my primary and Tricare for Life as my secondary. I shouldn't have too much of a problem getting approved, right?

[Carrie_C 9]

I think it probably means 100 pounds overweight, not %. It sounds like you meet that requirement. I think as long as your BMI is over 40 that is considered 100 pounds overweight.

[minpinmom 2]

Mine, Tricare Prime is the same way, they don't care about your BMI. Since they are both government agencies, they will probably both use the same Met Life Chart. Here is the link:

Met life ideal height weight tables references

At 5'0", even if you have a LARGE Frame, Met Life says you should weigh 122-137lbs. You will have to be 200% over both ends , so 137 X 200% = 274lbs You will make it under the 200% side, so you won't need to worry about your co-morbidities. WooHOO! This is how I made it too.

Good Luck and keep us updated.

[Wheetsin 714]

I'm 5 ft tall and weigh 350 pounds (gulp).

That gives you a BMI very near 70 (68.3). Many surgeons will not perform band (or laparoscopic, or sometimes "period") surgeries on patients with BMIs over 60 (super super morbidly obese) and may require diet or some other intervention to bring the BMI down to 60 before being willing to operate. This is because of the extra risks -- both with the general and actual procedures. So since you're at the insurance stage, it may not hurt to start contacting some of the surgeons you're considering and asking them what their cut-off for BMI is. That will help you build a stronger big picture as to what you're looking at. For you, a BMI of 60 is going to be around 305 lbs (again, estimate based on standard charts).

If my insurance says I have to be 100% over what should be my normal weight, PLUS comorbidities, BUT if I'm 200% over what should be my normal weight I don't have to go through the comorbidities workup, how do I know which catagory I fit in?

Per the standard BMI charts, you "should" weight about 125 lbs (based only on your height). 250 is 100% overweight, and 375 is 200% overweight, so it sounds like you're between the two categories. Unless my math is wrong.

[Wheetsin 714]

You will have to be 200% over both ends , so 137 X 200% = 274lbs You will make it under the 200% side, so you won't need to worry about your co-morbidities.

100% over 137 is 274, not 200%, no?

Here's how I'm figuring it. For every 100% you add the original weight once, so if someone weights 100 lbs, then they're 100% overweight when they weigh 200, 300% overweight when they weigh 300, etc. So to be 200% overweight, with an ideal weight of 137, you'd have to be 411 lbs.

Maybe check the numbers with your carrier. That way you know for sure. :crying:

[minpinmom 2]

That sounds like it makes more sense. But with my insurance I had to be 200% over the high end of my ideal weight. With her ideal weight for 5" tall, Large frame is: 137lbs. So, you figure what 200% of what that is, which is 137 X 200% = 274lbs is 200% over her ideal body weight. This is how Tricare figures it - and how I was approved. I was only a few lbs of being approved. And I didn't have any co-morbidities. I was 259lbs, 5'4". I can only assume they put me in as small boned (nice to be small something:-) My ideal weight was 114 - 127. 127 X 200% = 254. This is what Tricare told me, NOW, with that said, it sure wouldn't hurt my feelings if they were wrong and I got the surgery paid for anyhow!

Edited March 31, 2008 by minpinmom

[Mattie 0]

I'm not even sure I have to get approval in advance from Tricare. I have Medicare as my primary and for everything I do, the bill goes to Medicare first and they automatically forward the remainder (20%) to Tricare for Life. Which is a whole different procedure than when we had Tricare Prime.

When I was declared permanently disabled, and became eligible for Medicare, Tricare changed me from Prime to Tricare for Life.

But I am going to call them and ask. I already know that Medicare will pay for the LB. But since I never have to get preauthorizations for anything else, I doubt that I'll have to do it for this.

I'm totally devastated by what Wheetsin said. That I'm TOO big for a lap banding. There's no way I'm going to let them reconstruct my organs and I really feel that it's just so much more dangerous to do a bypass.

I'm just at a total loss now.

[minpinmom 2]

I don't think she was saying that for sure with your Insurance, but some insurances consider that. (Tricare doesn't) I will keep my fingers crossed for you that Medicare doesn't either. My husband (who doesn't need WLS) is in your boat, he was medically retired by the AF, and the VA has him permenant and total. So he is on Medicare and Tricare for Life. (It has been a breeze for all of his stuff). I sure hope this will be a breeze for you as well.

[ready_2_lose 0]

I am so happy to have found this site! A friend of mine got banded and is loving it and said that her surgeon just recently started accepting Tricare Prime so I called them. They do accept but need to have a PCM referral. So, on post I go to ask for a referral. Doctor wrote up all kinds of history, said my BMI is only (ha!) 38. I have many co-morbidities -- heart disease in the family, Diabetes in the family, I am high risk for these. So I am sitting and waiting to see if my referral will be accepted. Has anyone had luck with referrals like this with Tricare?

I am excited and I want this really bad!

[Wheetsin 714]

I'm totally devastated by what Wheetsin said. That I'm TOO big for a lap banding. There's no way I'm going to let them reconstruct my organs and I really feel that it's just so much more dangerous to do a bypass.

Wait a minute, that's not what I said. I was trying to help you with info, but you need to not get completely discouraged by something I didn't even say. I'm not even qualified to begin making a ruling on something like that, and wouldn't presume to do so. What I said was (abbreviated):

Many surgeons will not perform...surgeries on patients with BMIs over 60...and may require diet or some other intervention to bring the BMI down to 60 before being willing to operate...it may not hurt to start contacting some of the surgeons you're considering and asking them what their cut-off for BMI is.

I believe my surgeon's cut-off is 60, and that's the cut-off I've most often heard. That's not to say they will never do the surgery, I'm sure there have been exceptions. And the BMI AFAIK is a guideline for lap procedures - it may not apply to open. And I'm sure they've found ways to work with people to help get their BMI to a safer range.