Low BMI - Highmark PPO Blue (BC/BS) of PA, Help!

[Band_Groupie 3]

I'm a Newbie (2nd post) and I need some help (sorry in advance for the length, but I'm hoping someone can throw me a lifeline). I'm 49 and have been successfully dieting for 30+ years...so why am I fat (I'm the Yo-Yo Queen!). My health started deteriorating at age 45, it became harder to lose, and I started giving up hope, which isn't like me. My family history (4 siblings and I'm the "skinny one"), is a nightmare of obesity related issues- Diabetes, Stroke, Heart Attacks, Hypertension, sleep Apnea...etc. I can feel myself "circling the drain". But I don't have a diagnosis of any of, what I'm learning are the "Big 4" comorbidities---Did sleep study-neg., borderline cholesterol, didn't do the fasting diabetes test but reg. blood test came out borderline he did another simple blood test that looks at some number that show if you've had sugar issues over the past month and it was OK, my blood pressure has been high (140 something over 90-96) the last few Dr. visits but not sure what it takes for an official hypertension diagnosis (although I'm wondering if I don't qualify as hypertensive). I've got many minor comorbidities. I've developed adult onset asthma a few years ago, exertional dyspnea- shortness of breath, osteoarthritis, had a hysterectomy and bladder sling surgery both for incontinence which has since failed so I'm currently starting testing for another possible surgery.

I decided to "just look" at Lap Band a few months ago. After weeks of research and lurking here I saw that it was the perfect answer for me. I brought it up with my PCP who didn't discourage me, but said I wasn't the typical "Metobolic Nightmare", and he gave me some Dr. names. I had recently lost weight on the Alli pills/diet so I was just under a 35 BMI then and I asked for a diet plan which they gave me.

I got the insurance info. from Highmark PPO Blue (need 35-40 BMI with comorbidity and 6 mo. diet). And no, self-pay is not an option for us with 2 kids in college. I then signed up for 3 hospital's intro. seminars in Pittsburgh to find out as much as I can and to select a possible Dr...especially since it's a longer term commitment. I've since found that it looks like most people only go to one...not sure why since each seminar gave me new information/very different approaches. I went back to my PCP to further discuss this and was 1 pound below 35 BMI.

I stopped the diet and have now attended 2 of the seminars (I was at a 36/37 BMI then). The first at St. Margaret's (Dr. Means) never even called me after. The second at Magee (Dr. Eid), called and said they thought I wouldn't get approved, but I could pursue it if I want. I asked if I should call them back if I get the diagnosis of hypertension (since I'm thinking I'm qualified by my numbers and I haven't asked my PCP if I am officially hypertensive yet), but Magee didn't give me the warm fuzzies that even this would do it (Does it take more than one comorbidity? Insur. doesn't say so). I suddenly went from so hopeful to very discouraged.

I go back to my PCP for a weigh in on Monday. I was planning to "restart the diet" then as my BMI is closer to 37 now and in the seminars they said they need to see some weight loss, but not below the min. BMI. I'm trying to pull together some info. on what my PCP needs to document at these visits (thought I'd give them a form to fill in each time, but I can't find one). Do I need to journal anything? I also planned to discuss my blood pressure numbers and what the cut off is for hypertension. Do I need to be on blood pressure medication for it to be considered a comorbidity? What else can I do with the PCP that would help my approval? I'm scheduled to go to Allegheny General's seminar next Thurs., 13th. Is there something else I need to provide at the seminar that would help with approval?

My husband just announced that his insurance will be probably be changing in June as the status of the joint-venture he works for changes...let's see 6 mo. would be done mid May...AHHH! I know I would be the poster child for Lap Band after everything I've read...I can follow any diet, I used to teach exercise classes, I can hardly move without pain now...why is this so difficult? :frown: I need some input...should I just give up now or what else can I do? :thumbs_up: Thanks for reading....

[ksill18 0]

I would keep trying. Keep your weight the same during the 6 month diet monitoring. 1 co-morbid condition is all i needed. My BMI is 40.1 though. But with the history in your family going down in weight would be going away from those problems. Keep going and go for it!!!! i wish you luck!

[Luv2scuba 0]

Hi,

I have a BCBS PPO, mine is a national account. My requirements were BMI of at least 40, 35 with 2 comorbidities; 6 month supervised diet (WW, Jenny Craig count), a psych eval and nutritional eval. I live in PA too, north of you by the sounds of it. I'm facing the same problem. I have no comorbitities and my BMI is hovering between 40 and 40.5. I'm trying to exercise and eat healthy. Doing my supervised now, losing a lb a month. I see the surgeon on the 20th and hoping that then i can really start losing. This may sound terrible but I drink lots of Water before my appt to weigh in, to keep my weight up there and i make my appts for late afternoon. Self pay is not an option for me right now, so i'm doing everything i can to stay above that 40 BMI mark, without gaining back a lot of weight. It's taken me over 2 years to lose what i have and i'm not willing to go back there.

I've read on here that people will complain of joint pain, etc. to get that 2nd Co-morbidity. I'd talk to your pcp and see what he says about the Hypertension and see if he can come up with another one for you.

Good luck and keep posting, so we know how you make out!

[Band_Groupie 3]

Thanks all. Love2Scuba - Which hospital are you using? Does your BCBS plan actually say "2" comorbidities if you're 35-40 BMI? Mine doesn't say "2" but does use the word "comorbidities" plural, so I guess that's the same thing. I'll work on the PCP this week, but they're not real supportive since I'm at the edge. I hope my weight last visit being one pound below the 35 BMI doesn't bite me in the butt (yep, that was with water...had to ask to go to the bathroom while she went to look for Dr. names...incontinence...it's a terrible thing). I hope she'll let me start fresh...hoping my BMI will be almost 37...wish I could reschedule for the afternoon (good tip), but it's first thing Monday and they're closed all weekend. BCBS says you can use the PCP for the diet but they need to be working in conjunction with a dietician...does your say that, and how did you do that? My PCP just gave me the "American Fare" plan with sample meals. Do you need to see a dietician at the beginning (I know if the surgeons office accepts me I'll be seeing their dietician...but they all said that is just before you start the pre-op diet)? Thanks for the support!

[soxaholic 0]

Ohhh, Groupie, I am right there with you...almost to the T. Over the last five years, I have also fluctuated between 30-36 BMI (though mine has been more of a gradual climb).

I finally hit rock bottom a couple of months ago and started seriously considering lap band (you know when you state that you're fat and your friends stop with the automatic, "no you're not!" Yeah, that was my "straw" so to speak.)

The only of the big co-morbids that I have is high blood pressure. Over the last year or so, it has consistently been high enough to be considered hypertension. However, I am not yet medicated (my doctor wanted me to try to get it down with diet and weight loss...clearly, no luck). YES, you absolutely need to be on medication for it to be considered hypertension (or high cholesterol, GERD, any of those things). Diagnosed to insurance companies means medication. A couple of Dr. offices confirmed this when I called for consults. Ugh. I also have a ton of smaller co-morbids: Polycystic Ovary Syndrome, joint pain, acid reflux, etc. that I hope to use to beef up the high BP.

But I, like you, need that darn hypertension diagnosis. I don't really care for my PCP and I'm fearful that she won't support the surgery as it is. I'm even more fearful to tackle the BP medication thing. Do you tell her you need to go on it to help get the lap band? Or do you take it up as a completely separate issue and hope she doesn't see what you're up to? I don't know...but worst case would be "I think you're looking for the easy way out, and no, I won't medicate you."

By BCBS of MA says "one or more of the following..." I think you need either two biggies or one big and a few smaller to back it up.

Not fun. Keep me posted, and of course, GOOD luck!

[Luv2scuba 0]

Band Groupie,

I decided to go to Erie and I'm using Hamot and Dr. Ali.

Yes, they actually told me (and I have it in writing) 2 co-morbitities if you are between 35 and 40.

My PCP is very supportive, he knows how hard i've struggled. I did a five year diet history for him to put in my chart (his records). I have a definate family history for diabetes and stroke, so as i look at it, i'm playing with fire if i don't do something.

By the way, incontinence can be used, or so i've heard.

My BCBS requires a supervised diet for 6 months, can be Jenny Craig or Weight Watchers. And the 6 months don't have to be consecutive, 2 3-month consecutive diets will work. I did weight watchters in 2007. I sent my dates to them and they said they would qualify as long as i had my surgery before Jan 24, 2009 which is when i had my first weigh in with WW. I'm not sure that my surgery will before that as i've had to wait for 4 months to see the surgeon. So while i was waiting i started a medically supervised diet, just in case. I don't need it be supervised by a dietician. My PCP talked about the bandster diet that i would be following after and so we decided that South beach would be the best way to prepare for those changes. So that is what i'm following. I'm following it, but eating larger portions so i don't fall below 40 before the 20th. I haven't seen a dietician yet and wont until i see the one the surgeon uses.

I've heard that it is the the weight when you see the surgeon that counts for your BMI.

Good luck with your PCP. Drink lots if you can, keep your keys, cell, loose change in your pockets and wear heavy clothes.

It's funny how different our plans are for the same co and plan. I guess the different states make the difference.

I question a lot of stuff in email thru HCBO.com. Can you access that? I have kept and printed all the correspondence with them, just in case.

Let me know how you make out on Monday!

Pat

[Band_Groupie 3]

Sox- Glad to know someone in the same boat. I’m putting together a family health history to show my PCP….hope that will help show why I need this. I’m also going to ask about being put on medication for the hypertension…diet hasn’t changed anything and I know from talking to my siblings that I’m at the point they were when they were put on it anyway…so it’s not like I don’t need the meds- I figure it can’t hurt to ask. I’d rather be disappointed now than 6 months from now.

Pat- I’ve been on some of the BCBS sites others have mentioned from other areas/states. It’s amazing how different they are and how specific some are (IL one was very clear)...my Highmark policy copy I got is so vague “40 or a BMI of 35 with comorbidities (e.g., hypertension, cardiovascular heart disease, dyslipidemia, diabetes mellitus type II, sleep apnea).” Does that mean I need 2 of just those or can I have several other ones? Who knows! And mine won’t accept WW or Jenny Craig…has to be “supervised an monitored by a physician working cooperation with dieticians and/or nutritionists”…so is just my PCP good enough? I tried to get on your HCBO.com site and our account numbers aren’t the same…must not include Highmark. I asked my husband and he said he’ll get me the online link for asking questions to Highmark…good suggestion and way to document the specifics they want.

I’m bulking up Water for tomorrow (geez) and I’ll let you all know what happens.

[lapthismargaret 0]

I havent posted in awhile put today is different !!!!

I have capital blue cross blue shield pa. I WAS APPROVED!!!

I also am at the barely making mark! my bmi is 40 just making it ..i have no co morbities....MY FAMILY HISTORY WAS THE KEY.........I orig.was going to mexico to do surgery then my friends enouraged me to just try the insurance route....so i thought what do i have to lose!!!!!

i have done the yo yo diets and weight ...

Iwent in aug to the seminar i did the pre req that the ins requires my doctor signed off on the six wek diet that is req( by the way ) the bariatric doctors have the forms that the req the pcp to fill in for the 6 month weight lose program so dont worry about what to fill out !they acctually preferre you use there forms! atleast that how it worked for me!!

hang in there ......it will all work out! i cant believe it 12-09-08 is my surgery date!!!!!!

[Band_Groupie 3]

Whoo Hoo Margaret! I'm so happy for you!!! You go girl!!!:thumbup:

I still don't get the family history piece (although according to my Highmark BCBS plan you wouldn't need anything with a BMI of 40 but the 6 mo. diet). When I got the call from Magee that I probably wouldn't get approved I asked specifically if insurance ever considers family history and she said no. Both the seminars I went to didn't ask anything about family history on their initial forms (I think they do on the longer packet you fill out once you're accepted into their program).

I just got back from my PCP initial visit and I had already typed up a list of the my family history comorbidities of obesity. My PCP was definitely concerned after she looked through it (it's one of the main reasons I started looking into this after my sister had her stroke). I'm going to include it with the rest of the paperwork for insurance, especially after hearing that family history helped you. My blood pressure was still high today (158/110) so when the Dr. came in I did ask her at what numbers does this become hypertension? After looking over my long history of high numbers and that most of my family is on meds for BP, she started me on the meds. I guess this is a good thing...for insurance at least (1 more comorbidity), and actually for my health. I weighed heavy- at a 37.7 BMI so I'm good for the diet now. Wish me luck...I go to the AGH Seminar on Thursday and I'm hoping I look like a good candidate now. I SO need this for my health!

[Luv2scuba 0]

Congratulations Margaret!

I'm so happy that you got approved! That is so great!

Keep us informed on you progress, please!

[Luv2scuba 0]

Band Groupie,

Sounds like your making progress! I'm sure Thursday will get a lot of your questions answered. I think that getting on meds will help your case with the insurance. I've read where a lot of people find out they have sleep apnea when they start this process.

I'm really looking forward to going next week for my appt with the surgeon to see just how and when things will happen too!

Pat

[Band_Groupie 3]

Pat---I forgot to tell you...please glance through my blog for today "I peed my pants". I was thinking of you as I added my phone to my belt! -BG