Co-Morbidities Resistant to Medical Treatment?

[CuriousJ 0]

Has anyone here had experience with Calpers Blue Shield HMO? Per instructions at the seminar I attended last night, I called my HMO to ask some questions about coverage of weight loss surgery. The answers were all what I had been led to expect -- BMI of 40-49, no co-morbidities; BMI of 35+ plus one severe co-morbidity, no other documentation.

Here's the catch -- in order for the co-morbidity to "count," it must be resistant to "intensive medical therapies." So, in other words, if I have HBP and diabetes that can be controlled by medication, these co-morbids cannot be used to justify weight loss surgery. This makes no sense to me -- I thought insurances approved WLS to get people off these drugs! The only other approved co-morbid is sleep apnea -- I've never been tested, but I've heard most obese people suffer from it.

At the same time, the member services representative kept stressing that the medical group "knew the guidelines" and would present the "appropriate package" if it recommended WLS. So, I am really confused. Will the medical group "finesse" the package they submit to my insurance? Will they simply have me do the sleep apnea test, with the expectation that I will suffer from that condition? Has anyone else heard of these co-morbidity restrictions for WLS?

If so, could you please share? As I said, I'm really confused ...

[adagray 1]

Aetna has this rqmt for high bp. They say it has to be 'medically refractory' which basically means that it is still high despite 'optimal medical management'. Luckily for me, I have terrible white coat hypertension (meaning mine always spikes when I go to the doctor anyway) so I have lots of high readings at the doctor's office even if it is pretty well controlled otherwise. I am going for a sleep study as well, though, just in case my high bp is not enough. The silly thing is that if someone wanted to trick the system, they could just not take their bp medicine that morning. Or, take some pseudaphed (sp?). Not that I'm suggesting these things, but for someone w/high bp to begin w/its easy to get a high reading if they need one.

[CuriousJ 0]

Aetna has this rqmt for high bp. They say it has to be 'medically refractory' which basically means that it is still high despite 'optimal medical management'. Luckily for me, I have terrible white coat hypertension (meaning mine always spikes when I go to the doctor anyway) so I have lots of high readings at the doctor's office even if it is pretty well controlled otherwise. I am going for a sleep study as well, though, just in case my high bp is not enough. The silly thing is that if someone wanted to trick the system, they could just not take their bp medicine that morning. Or, take some pseudaphed (sp?). Not that I'm suggesting these things, but for someone w/high bp to begin w/its easy to get a high reading if they need one.

thanks AdaGray -- I do have, I think, two severe co-morbidities -- HBP, which was initially resistant to treatment, but now seems to be working (after PCP doubled starting dosage). I've also learned from my endocrinologist that I was pre-diabetic a year ago. My PBP didn't say anything about that to me, and my endo thinks there's a good chance I'm diabletic now. I get my blood sugars tested next week.

so, taking sudafed spikes HP? I didn't know that ... hmmmm. It's funny, but I was thinking that the stress alone was going to start driving my BP up! I was also desperate enough to think that I could stop taking my thyroid meds for a month and easily gain 20 lbs, which makes the whole point moot, because that would drive my BMI up to 40. I really really don't want to start at any higher weight, though, expecially since my bariactric surgeons are notorious for pushing gastric bypass over the band, and equally notorious for being ultra-conservative with the fills ...

Anyway, thanks so much for the info -- please let me know how your approvals go. I am glad that my insurance doesn't force me to document five years back, as that would really be difficult for me. Good luck to you!