Am I Paranoid? Mildly Freaked Out Or What?

[sleevemeup 41]

Good Morning,

I will try not to go on and on. I went to my seminar last week. I had called my insurance company (they do cover wls). We have had this insurance for over 7 years. They don't really seem to have much of a criteria other than having a bmi of 40 or higher, and proof of failed weight loss. Of which, I have a bmi just at 40. And I have tried everything. My pcp has suggested surgery as an option as well. My insurance company covers my many meds, 4 knee surgeries, and a few other things.

It just seems a little too easy. They do have an outside pre-cert company that will go through the info submitted. I am wondering if I will initially be approved and after following my surgeon's mandatory 3 month pre-op program they will deny me at the last minute if I go under 40 bmi. Does anyone have input?

Also, I believe I may have PCOS which at my age (47), I am not obviously going to have anymore kids- but I do believe it has contributed to my inability to loose and maintain the loss. I know this is the tool I need to regain my active life.

[massindex 346]

If you fall below 40 BMI, they likely would deny you coverage. If an insurance company can find a reason to deny you, they will. For my wife, it was 35 (I'm self-pay so it didn't matter but I was 50+ anyway). We kept her at that weight until the day of the surgery just to make sure it wouldn't happen.

[karenb4729 309]

I have UHC and needed 5 yrs documented at a BMI of 40 or more. I had that when I got the referral to the outside company they use - Optima. Since then my BMI has dropped while I have been doing the pre-op diet and all my medical appts and I'm under the 40 but I still received approval for my June 4th surgery. I don't know who your insurance company is but usually once you send in your documentation for the BMI they aren't going to ask you to weigh in again.

[MinaT 669]

Many insurances companys have a 35 bmi with 2 comorbidities and 40 with 1. So if you have obstructive sleep apnea, pre-diabetes, high blood pressure, etc. that usually topples the need for 40 bmi.

Most insurance companies expect you to show initiative to lose during the weight loss and your surgeon will definitely frown upon you gaining weight during that time. Anyone can lose weight when they are being supervised and told to eat High Protein, low carb, it's the maintaining the diet that's hard. They aren't going to punish you because you try hard during the 3 months to follow the doctor's instruction and if you hit 39 or 38 bmi they will punish you for it. I lost almost 60 pounds before my certification and all it does is help me in the long run.

[Marisa46 7]

If you your insurance company has a bariatric coordinator then the best thing you can do is ask. In the long run studies have shown that insurance companies save money by covering weight loss surgery. The health problems associated with obesity are expensive. But honestly you are having surgery next week! In my experience once your approved and have a date then your submission process is over.

It sounds like you have good coverage. Most likely what people who work with benefits call a "cadillac plan". How generous your insurance plan is allowed to be determines how you are treated.

[raindrop 5]

Your first initial BMI is the one they should go by. So regardless if you fall below after they should take that 40 bmi. Also sometimes the employer may have different requirements then the insurance. That's where the outside company that reviews comes in. I ran into that problem and found out at the end that the employer wanted some more requirements then the insurance company. Luckily it worked out for me in the end I'm getting sleeved June 5.

[sleevemeup 41]

Your first initial BMI is the one they should go by. So regardless if you fall below after they should take that 40 bmi. Also sometimes the employer may have different requirements then the insurance. That's where the outside company that reviews comes in. I ran into that problem and found out at the end that the employer wanted some more requirements then the insurance company. Luckily it worked out for me in the end I'm getting sleeved June 5.

That is what I thought. They do have an outside company that pre-certifies the surgery. When I spoke with them, they were very vague as to what is required other than a 40 bmi. We have a teamsters policy, which is pretty good, they have covered everything that has ever been presented. Another plus, they have covered me for almost 9 years, so they know and have paid for all of the problems that my weight has caused including several orthopedic surgeries. I have my consult on June 8!