ccol625

Does anyone know the weight the insurance companies go by for approval? Do they go by the initial consult weight or do they go by your current weight? I am in the appeals process but was just wondering if I get denied again. I may need to gain 6-7lbs to reach a BMI of 40 since I was denied with a BMI of 38.73.

Good Morning. I am a 46yr old single mother of 2 boys (one on the autism spectrum). I started my journey in Dec and went for my pre op appt with the doctor last week. I had told my mother in December that I was contemplating the sleeve and she said she didn't think I needed it and that I should do it on my own. Needless to say, I am just like the rest of you....I have lost weight only to gain it back. I have been overweight as far as I can remember....1st-2nd grade. I stopped by my parents house yesterday for my Mom's bday and told her I was waiting for approval and looking at a surgery date of 3/31 and she again told me she didn't approve and wouldn't support my decision. I know I am a grown adult and can make my own decisions, and WILL have this surgery, but why am I so disappointed and sad that she doesn't give me her blessing and well wishes? I am doing this for me and my health. She could have said that she would support me even if she didn't agree with my decision. Moving on with my new life and health journey.

@@mykdzmom, thank you for your support. It is definitely nerve racking. @@bncbabe2015, definitely check with the doctor before starting this process. Also I suggest to call your insurance and verify with them, what weight they base their decision on. @wilflowergirl, if you have sleep apnea and a BMI of 40, you should qualify for surgery. It is crazy how many different rules each insurance company has...each plan is different and each company is different. There should be a default on the minimum requirements for every company and everyone should follow the same. Good luck to everyone!!!

@@fox99, that is exactly how I am. I was so surprised I was so disappointed and upset with my mom NOT giving me her approval. I know it is my decision and I will do it...once the damn insurance approves it....but I never realized how much I still rely on my parents approval. My father doesn't say anything. He stays out of conversations like this one...smart man...lol @@Essence46, Congrats on making the decision and going thru with it. I feel exactly like you do. As for your sister, this is why I won't let my mothers disapproval hold me back. I know what I need to do for my health. I can lose weight, but I can NEVER keep it off. I need something permanent to help.

@@x0CheekzVSG, thank you for your comment. My mother said the same exact words to me...it is so upsetting, however I am still moving forward with my surgery. Of course, my insurance company originally denied my request so now I have an appeal processing and I am still hoping to have my surgery on 3/31. If my appeal gets denied, then the office will request a peer to peer review. I was denied because my BMI is 38.73 with no MAJOR co morbidities. Fabulous I am not fat enough or sick enough to be approved...SMH. @@MsAlaineus, thank you for your support. I am doing what I need to do for my health no matter what my mother's opinion is. She will be happy after she sees me healthy....altho I am sure she will continue to say, "well you could have done it on your own". lol

@@scoutmom, the insurance doesn't require any weight loss on the "supervised diet", however they really don't expect you to gain weight since you are suppose to be showing them you can control your eating habits prior to the surgery. If you have a BMI of 40, you automatically meet the requirements so should be approved without a problem. @ taweedeegirl, I started at a BMI of 37-38 and thought I definitely had sleep apnea, however never was professionally tested for it. After the sleep study test, it came back I had some sleep abnormalities but did not have sleep apnea, so there went my major co-morbidity. I had gained some weight in February because I was eating everything in sight "thinking" I might as well eat it now before I have the surgery, but then the nutritionist told me I should lose it in case the insurance denied me because I don't have control of my eating. I lost the weight by my March nutritionist visit, however I was back at a BMI of 38.73. The insurance is saying because my BMI is below 40 and I have no major co-morbidities I don't qualify for surgery. I called my surgeons office Monday as well as the insurance company and we are appealing their decision. I received an email from BC/BS yesterday saying they would have a decision for me by 3/24 the latest and that my case is being reviewed again. Fingers crossed I hear something before then since I need to start the pre op diet next week on 3/17-3/18 and if they deny it, at least I would still have 2 weeks time to schedule a peer to peer review. I work in the medical field and "usually" if a doctor speaks to the insurance companies doctors, procedures get approved. I have yet to hear of a procedure a doctor recommends being denied after the doctor speaks to someone in charge of the case at the insurance company.

@@scoutmom, I have empire BC/BS. Same thing happened to me. They said I should have no problem getting approved and then my sleep study came back with some abnormalities but not obstructive sleep apnea so there went my major co morbidity. When I went to my NUT visit in feb I had gained almost 10lbs due to many good funerals. My NUT told me I had to lose weight if I wanted the insurance to approve. So when I went in March I lost 6lbs and was so proud of myself since I was on vacation the week before. They told me not to worry and all would be good. When I went for the pre op appt with the surgeon he was the first to scare me that I was in the "gray" zone being that my BMI wasn't over 40 and I had medical issues but nothing the insurance company considered major. So here I am waiting to see what the appeals process does. Sucks since I like to know what I am doing. It is killing me being in limbo. Ugh

It is funny you suggest the weights because each time I have gone for my NUT visits I have been emptying every pocket and taking off my boots and anything that isn't part of my body so I don't gain weight. The sucky thing is I was 2 lbs away from a BMI of 40 in Feb for my NUT visit due to food funerals, but was told to lose weight so my insurance company wouldn't deny me for not losing weight or maintaining it during my NUT visits. And I specifically asked would it be easier to qualify if I gained another 2-3lbs to have a BMI of 40 and she told me no. Now I MAY have to add another 2 months of NUT visits and gain the stupid 6 lbs to get to the BMI of 40. I was scheduled for my surgery on 3/31 and altho I have my case in for an appeal, I am already trying to accept it may not be until May now. :-(

@@bikrchk, thank you for your response. I started this process in Dec and was told the co-morbidities I have were enough, but when my dr's office submitted the documents to my insurance BC/BS they denied the surgery. Granted I have spoken to the insurance company and they have the incorrect BMI so hopefully that will help my case. I had just been wondering since I am so close to having a BMI of 40, will the insurance company say I need additional NUT visits if I gain weight? This process sucks because you seem to be damned if you do and damned if you don't.

@cdenny123, thank you because I think that is the route I will have to go down. Did you gain before the 1st consult or during the "supervised diet" nutritional visits? Do you know if they base this on your first /original weight or the most recent?

I received the call from BC/BS that my procedure was denied due to my BMI being too low. They have my BMI as 36.6, however when I calculate I get 38.73, so I think they have the incorrect weight and height from my doctors office. Although, I have some co-morbidities, I don't have any MAJOR ones so they say I'm not a candidate. I told them so if I gain 6 lbs and have a BMI of 40, I would be approved and they said yes. Well guess what I plan on doing? My doctors office said they will appeal and if the written appeal gets denied, then they will ask for a peer to peer meeting. I am scheduled for the sleeve on 3/31 so I am hoping the news will change before then or else I will be eating everything in site so I can gain 6 lbs and have a higher BMI. It really SUCKS that I have to gain weight to get approved. Anyone have any advice on how to get approved without gaining weight?

@ samuelsmom, thank you for your advice. I have written an appeals letter and emailed it today. I also called the case manager and left a message. Of course she called me back but I missed the call because I work in a hospital myself and was tending to a patient. Called back again and left another message. The surgical coordinator also contacted me saying she called the case manager on Friday and left a message but hasn't heard back. She will try again this afternoon if she hasn't heard anything. And yes I think I could easily put on 6 lbs over a weekend as well. Wish me luck!!!

Thank you Pepper123 but the surgical coordinator is the one that said she would submit the written appeal and if that got denied she would submit for a peer to peer review/meeting

I was told you may not see ketosis on the urine strip because it isn't the same as diabetic ketosis.

Oh BTW, I am heartbroken about this denial too. I am a single mom and had it all planned out to have the surgery done the week my kids were on spring break so they could go to their grandmas house so I wouldn't have to worry about getting someone to bring them to school and back etc. I don't know what I will do if I can't have this done at the end of the month.

Congrats to you!!! I am going through the appeals process right now. I got the call from my insurance company (BC/BS) yesterday that the request was denied and I almost had a breakdown. I called the doctors office and insurance company today. The doctors office gave the incorrect BMI so hopefully that will help my case. Of course my BMI is 38.73 so still in the gray zone. I was 39.67 last month and I was told I needed to lose weight for my insurance company to possibly approve me. I don't have any major co-morbidities, however have hypothyroidism, high cholesterol, severe GERD with Barrett's syndrome (precursor to cancer), and stress urinary incontinence. I have had a BMI in the last 5 years as high as 42 so I am right there. I may have to gain 6-7lbs to be over the 40 BMI to guarantee approval. It just sucks that I have to gain a couple of pounds to qualify. Hoping the appeals process will work in my favor since I am already on the OR schedule for 3/31. Congratulations again and wish me luck too!!!

Thank you Jenwith. I know my mom isn't supportive because it is surgery. She is a retired nurse so any kind of "elective" surgery is unnecessary even if your health will benefit from it. She told me it is a lifestyle change and that she wasn't sure I was able to do it. I don't think she understands that even though I will still have to watch what I eat after I lose the weight, I will be able to eat whatever I want, just smaller portions. Plus when I tried to explain it to her, she doesn't want to listen to me because she has already made up her mind. I am very close to my mother so this is heartbreaking for me. My 2 sisters are on board and think it is great that I am doing something to help me KEEP off the weight this time. 2 years ago I lost over 50lbs and felt terrific....as usual, when I started eating regular food, I gain the 50 back plus an additional 20lbs. I hate the way I feel especially since I know how great I felt 2 years ago. I had really hoped my mom would come around before I had the surgery, but maybe she will change her mind when she sees the results. It is my life and my decision and I am committed to myself and a better, happier and healthy life.

My date is March 31st!!! So excited to start my new life. Anyone else March 31st?

I got my date today for 3/31, but they told me they are submitting all the paperwork to the insurance today so hopefully I will hear if I am approved or not by next week. They told me it could take up to 14 days, but it doesn't seem like it has taken anyone that long to hear back from their insurance company.

I'm with you too. Went to my 3rd nut appt and gained 7-8 lbs. I know why though. I went through the "I might as well eat it now because I won't be able to after" phase. I too have hypothyroidism. My nut also told me that I needed to lose the weight before my next appt or else the insurance may not approve me. I have been doing well the last week eating fish and veggies for dinner and having my shake for Breakfast and bringing lunch to work of tuna and a greek yogurt so I am increasing my Protein amount. I have also added exercise into my routine. I am going on vacation next week so will have to watch everything I eat but it will be worth it if I get approved for the surgery. I can't wait to start my new life.

I'm hoping to have it the end of March. My doctors won't give a date until after my next nut visit at the beginning of March. Then hopefully things will move along nicely. I wish it was today or tomorrow because I am ready to start my new life already!!!