BCBSIL-denial for too much pre-op weight loss?

[mandilou 1]

Hey folks-

I'm about three months into the 6 month supervised diet. I haven't lost a ton of weight, but at my most recent visit, I was asked to start using a food log. The plus side is, it has really whipped me into shape and kept me honest. The bad side is... well, it's really whipped me into shape and kept me honest.

I'm nowhere NEAR 35-40 BMI, but I'm currently only eating about 1300 calories a day. On this pace, I could lose over 30lbs (or more!) before a May surgery. Will I get denied?

My PCP also put me on Meridia, to help get some weight off before surgery. It's working, but I worry it will work TOO well. The WLS office said it's okay to be on the Meridia, and the insurance was okay with it.

So what to do? I want to give myself a good headstart, but I know that if I was just losing weight alone, it won't last... I've fought that battle enough times that I know I need the band for assistance.

What say you all?

[catho72 0]

Aetna denied me the first time the dr's office sent for approval. They said because I didn't have any co-morbidities and my BMI went below 40, they wouldn't cover it. When they appealed the decision, it was approved.

[mandilou 1]

cathy-

thanks for your input and congrats on the approval! :wink: Fortunately (or unfortunately?) ending up below 40 BMI isn't really going to be a problem. I have about 200lbs to lose, so I'm pretty confident I won't fall below that mark. Plus I do have comorbidities. I'm more concerned that when they see that I "can" lose 30 pounds, they'll say "oh, well she doesn't need this then", even though I really do for lifetime maintenance and success.

[mandilou 1]

Thought I would update this in case anyone else had the same question..

Spoke to the WLS nurse today at my clinic. She said that if my BMI doesn’t fall below 35 (it won’t), then I don’t have to worry about it. Also, she said they submit my ORIGINAL weight to insurance. So she said go ahead and lose weight, workout and keep up with the Meridia. She said it will just help me develop healthy habits. She’s glad I’m doing the food log and said having all that will really show I’m serious about the surgery and that I will stand a better chance of being successful with it.

[daco525 0]

I had my consult with the surgeons office on Friday. I was told not to lose more than 5 lbs. on the 6 month weigh in. My BMI is currently 39 with several co-morbidities. Maybe it depends on your ins. I have BCBS NJ, they said I could be denied if I am too successful.

[mandilou 1]

My guess would be that you're denial might be based on your BMI? Maybe they're worried you'd end up below 35?

Best wishes on your 6 month journey! :scared2: I'm halfway done and really excited! It is frustrating to have to wait 6 months, but I've found it's given me time to adapt good habits and prepare emotionally for the major changes I'm heading towards.

[daco525 0]

I have been able to go below 35 in the past but only to gain it all back and then some...story of my life...and many other people here. I did decide that two weeks before my last weigh in I am going to really begin eating healthy. I too want to begin making the changes and habits that will be needed for success. Best of luck to you. One great thing that happened at the surgeons office was I met a wonderful couple that was banded a year ago. Each one of them lost over 100 lbs. After talking to them I really know this is the right decision and I am even more motivated. I don't even know them and I am soooo proud of them!

[TQUAD64 9]

My insurance case manager told me not to go below a 40BMI on the 6-month supervised diet, because I risked not being approved. I stayed above the 40BMI, I until I was approved to see the surgeon. Once I saw the surgeon, I was able to really start losing weight, without the fear of being denied the banding surgery.

[Band_Groupie 3]

I'm about to start month 4 of my 6 mo. and am currently 4 pounds above the 35 BMI minimum. I just went to my surgeon's consult and was told I can't go below the 35 BMI at ANY time during my 6 mo., even after the surgeon consult. I have BCBS - Highmark PPO Blue (Western PA). The insurance company can look at the whole period of time since I have weight written on my monthly weigh-in forms (they can look at it all).