Overweight Friend, doctor says she doesn't qualify

[AJW2 0]

Hi all,

I'm in the process of getting approved, so this isn't about me.

I have a friend who's 5'-8" and 222 pounds. Her GP says her BMI isn't high enough and even though she is on 3 different BP medications and has insulin resistance and PCOS, he says she's too healthy for WLS and that her HMO Kaiser wouldn't approve her. Now this sounds very odd to me. I told her to go see a WLS and ask him/her about this not her GP. I don't know if she's just telling me this because she doesn't really want to do it (she says she does), or if her doctor is really saying these things. He said Kaiser wouldn't pay for it. What has your experience been in similar situations?

[paisleypea 1]

She needs to find out what Kaiser says. most have their medical policies on line. Blue Cross has it all spelled out so I knew what I needed to qualify. typically it takes a BMI of 40 or greater, OR a BMI of 35 with 2 co-morbidities

[DJSlim 0]

Hi , I have BCBS insurance. And they will not pay. She can use her Flexible Spending Account- if one is available. That's what I did, then I had an affordable surgery. The med insurance do not seem to care if you are overweight -because you will become their patient for life and buy meds.

See if she can get a loan - your life is surely worth it.

[paisleypea 1]

I have BCBS and they ARE paying. it all depends on your policy. Some employers cover bariatric surgery and some do not. I am lucky in that ours does.

[RestlessMonkey 7]

With a BMI of 33.8 her PCP is probably correct; although I am NOT familiar with the requirements Kaiser lists for WLS, most insurance companies (and many surgeons who accept self-pay) say that the BMI should be at least 35 w/co-morbidities.

Perhaps in your enthusiasm for the band you've swept your friend along a little?

If SHE wants it, she should research it; but you shouldn't pressure her. How we walk the "weight loss path" is something very individual; diet and exercise may still work for her at this point. Or maybe not, but let her decide.

[sarahbellzz14-4 1]

Most insurence will cover (if it's in their policy) if Your BMI is under 40 but you have at least 2 or more co-morbidities and are mandated to be under observation for medical & neutrition for at least 6 months, which is what I had to do. I have Health Plus here in NYC, I had to go to my dr. once a month for 6 months, get a psych evaluation, sleep study, EKG, Chest x-ray, Neutrition consultation as well as have 2 letters supporting the decision for my surgery, which I have severe hip arthritis so my orthopedist wrote a letter and provided my insurance with both my X-rays and MRI reports, I have sleep apnea, high cholesterol etc.... So I qualified in 7 days with my insurance. and I have the Sh*tty insurance, To the point where I was my surgeons first patient with it.

[AJW2 0]

I haven't pressured her at all, nor "swept" her along. I told her what I was doing; she started asking me a lot of questions about it and said she'd like to do it. I told her to do her own research and see if it was something she wanted to get into. She found the Kaiser doctor in her state who does it and wanted to tell her PCP all about it. He's the one who shot it down unless she wants to self-pay which of course she doesn't even though they have the money at the moment to spend on it, but I just don't think it's a priority, and that's fine too. To each their own.

With a BMI of 33.8 her PCP is probably correct; although I am NOT familiar with the requirements Kaiser lists for WLS, most insurance companies (and many surgeons who accept self-pay) say that the BMI should be at least 35 w/co-morbidities.

Perhaps in your enthusiasm for the band you've swept your friend along a little?

If SHE wants it, she should research it; but you shouldn't pressure her. How we walk the "weight loss path" is something very individual; diet and exercise may still work for her at this point. Or maybe not, but let her decide.

[RestlessMonkey 7]

I don't know if she's just telling me this because she doesn't really want to do it (she says she does), or if her doctor is really saying these things.

I got the implication that she may be reluctant from your post...but you know her! I don't know either of you. If she is interested, she should contact her insurance, find out their requirements, and take it from there, not rely on her PCP.

[AJW2 0]

That's the best advice and that's what I told her.

I got the implication that she may be reluctant from your post...but you know her! I don't know either of you. If she is interested, she should contact her insurance, find out their requirements, and take it from there, not rely on her PCP.