Hello. My name is Michelle and I am just starting this process. I went to the first seminar last night and will schedule my consult with the surgeon in a few days. I have BCBS of California.

My question is...My BMI is 36-37. Im 5ft 4.5in and weigh about 218. I have a past history of gestational diabetes, preecclampsia, infertility, suspected PCOS, and hpertension. I also have back/hip/feet pain (which I have never seen the Dr for but have had problems for years), abnormal or absent periods and I think my blood sugar is out of whack. I have tested it at home randomly and have gotten several readings in the 140's and once at 192. I go for bloodwork next Wed. I also have a family history of diabetes, uterine/cervical cancer and hypertension. The problem is, none of these seem like huge red flags and I have never been treated by a DR for any of them except the pregnancy related ones. Im afraid that my insurance will deny me. Any thoughts or advice?

Thank you!

Well, I doubt the insurance company would consider the pregnancy related issues as co-morbidities...the High Blood pressure is a definite co-m. Also, if you're pre-diabetic that's also a co-m. And don't worry, if you're denied the first time, there's always appeals. Right now the LapBand company is going to bat with our insurance company who denied my husband because his BMI is 60. They stipulate that they'll only cover for BMI's of 40-50 (35-40 with co-m's). Well of course there is nothing to substantiate that pre-determination and therefore LapBand is appealing for him. He's a little discouraged, but we're certain we'll prevail. I'm sure you'll prevail too! Probably on the first try. It's scary at first...there is a lot of confustion at the beginning and if you're anything like me, you want everything laid out in a straight line with specific instructions. Unfortunately, this isn't a "one size fits all" process. So, go for it! I think you'll be fine and banded before you know it

LMJ - BCBS is generally VERY good about paying for the surgery. Get your diabetes diagnosed. If you have hypertension and diabetes, they should cover with a BMI under 40. They did for me. I have BCBS of Massachusetts. No problem. My surgeon wrote the letter and they approved me in 2 weeks. Good luck!

LMJ

I have BCBS of Calf and just had surgery on the 4th of May. I do have co-m such as HTN and reflux. Also am pre diabetic. What I did when I went through all of the tests such as with pysch test and so on all the Dr was ready to submit all this to the insurance co was I wrote a letter. I described what my family history is like, how I am limited by my back, knee and hip pain. I also described that I have several family members who are 300-400 pounds. Along with that I sent a complete list of all of the diets I have ever been on and how much weight I lost (usually 12 pds and that is it) and how much I gained back. Like I said all of this went with the Dr's paperwork. I was approved 2 weeks later. I dont know if my letter helped but it didnt hurt. Good luck to you on your journey. Dont give up....keep trying. The most important thing is to continue to follow up with your physician to have things documented.

Susan

Thank you guys so much, you have been a great help. I will keep you posted. I will be scheduling my consult w/ the surgeon today.

mention the joint problems! If you need to see doc for those, then do that. Lower body joint issues and back problems are related to weight. Doctors have certainly told me enough times to lose weight for my fibro and my occasional lower back problems. Also, some people might wear weights when they go in the future to be weighed (a few rolls of quarters in the bra, a weight in the pocket of cargo pants, etc). Not that you should do this, I'm just saying, I've heard of this... Plus the menstrual stuff might be. Hypertension is definitely a comorbidity. Its one of mine. I also have reflux that I will always have, but it is worsened by weight. And I do think they look at family history and everything really. I was asked about that. So I explained that before my dad had cancer he was over 300 pounds and loved dairy queen (one of my earliest memories is eating ice cream with him in the middle of the night. I love dairy queen too). And that my mother was morbidly obese but when I was on college she lost 120 pounds with weight watchers and kept it off. I tried weight watchers and it drove me crazy, etc. She is hungry all the time, sort of obcessed with food I think. She says you get used to always being hungry. I don't think I can live like that-- I think that would just drive me crazy since I've tried so many diets that were like that and those didn't work because I was hungry. For me this was a big point of concern, as was future health. Everyone listened.

Are your blood sugars fasting or after eating? If after eating, how long after you eat are your sugars high? Your BS is supposed to be higher after eating, thus my questions.

My blood sugars are higher than normal after eating. I do know they are supposed to be higher of course, but they out of the normal range. Normal range for after eating is under 140 and I have had several higher than that....

Anything under 200 is not a concern when it comes to comorbidities and WLS.

Your BMI is 37.5:

Barix Clinics - Is Surgery Right For You - BMI Calculator

You have joint pain but it is not proven on xray that it is weight related. You have no medical history of hypertension or diabetes (for insurance purposes). Family history doesn't really matter in this case. Pregnacy complications don't really matter either for the sake of this discussion.

You have nothing to work with that I can see. You will either have to wait until you gain enough weight to have a BMI of 40 or more (not suggested), you can diet/exercise, or you can self pay. Most people here are self pay for surgery, we know it isn't easy.

After you do reach a BMI of 40 or more you may have to go on a six month medically supervised diet. If you go below a 40 BMI you may no longer qualify. If you don't lose weight you may not qualify. That means you may have to wait until you are a 43-44 BMI before the medically supervised diet will be effective.

This is all assuming your insurance does not exclude WLS and even if it does not, all insurance co's seem to have their own quirks and requirements.

Unless someone has some better info to offer (I am not an insurance expert by any stretch) it looks to me like you are looking at self pay or diet/exercise. In Mexico for an experienced surgeon that is around $8K give or take $500. If you are looking to the US for surgery from an experienced surgeon you are looking at around double that amount.

To be honest, your post was very upsetting to read. That EXACTLY what I afraid of, that I have a bunch of little problems but they dont add up to anything big. Thank you for being candid, I really appreciate that.:nervous

I go to the DR today to get some testing ordered which will hopefully might lead to insurance approval. I was hoping you may have some other tests in mind that I havent thought of. Here is what I have so far..

Blood glucose (I have had several sugars out of the normal >140 range, Hopefully I will get Dx w/ pre-diabetes)

Hormones (I know my hormones are out of whack, I have black whiskers on my chin/neck (sorry for the visual LOL), and I have very irregular periods like maybe 2/year and I have history w/ infertility and having to use fertility drugs to get pg)

Reflux testing (I have frequent heartburn but I have never thought of it as reflux, I just pop tums all the time!)

sleep study (I wake several times a night but Ive never thought of apnea. I hear its common, so who knows, it could be which would look good for insurance.)

Oh, and I will mention all of the hip/back/feet pain I have and see if there are any tests needed to prove that...

So thats what Ive got. Can you think of anything else?

Thanks again for your honesty...

LMJ

I hope you dont mind me saying this but you said you have a bunch of little problems that dont add up to anything big. In my own opinion I disagree...sure you dont have it documented and you are going to have to see your Dr and follow up with all of this but I think all of your symptoms could lead to something big if you leave them untreated. So even though you want the band the first step is make sure you see your primary care Dr and get your health problems diagnosed and get on the road to better health in general. Take your list of complaints to your Dr and have him/her address each and every issue.

As I said earlier I also have Blue Cross of CA. I am not sure what they looked at when trying to decide if I should be approved or not but I do know....for my policy..it was covered at 90%. As far as what their guildlines are for approval I do not know. Maybe you could talk to a case manager AFTER you see your Dr and see what they have to say as far as what they look at when trying to approve/deny the lap band surgery. I wish you sucess in your journey and hope that you do follow up on all of your symptoms. This might take a little bit longer than what you would like but hang in there!

Susan

Thank you Susan, you made me feel a bit better! For my policy LB is covered 100% w/ a $100 copay...So...Im looking forward to my appointment! Thanks again for your post.

To be honest, your post was very upsetting to read. That EXACTLY what I afraid of, that I have a bunch of little problems but they dont add up to anything big. Thank you for being candid, I really appreciate that.:nervous

I go to the DR today to get some testing ordered which will hopefully might lead to insurance approval. I was hoping you may have some other tests in mind that I havent thought of. Here is what I have so far..

Blood glucose (I have had several sugars out of the normal >140 range, Hopefully I will get Dx w/ pre-diabetes)

Hormones (I know my hormones are out of whack, I have black whiskers on my chin/neck (sorry for the visual LOL), and I have very irregular periods like maybe 2/year and I have history w/ infertility and having to use fertility drugs to get pg)

Reflux testing (I have frequent heartburn but I have never thought of it as reflux, I just pop tums all the time!)

sleep study (I wake several times a night but Ive never thought of apnea. I hear its common, so who knows, it could be which would look good for insurance.)

Oh, and I will mention all of the hip/back/feet pain I have and see if there are any tests needed to prove that...

So thats what Ive got. Can you think of anything else?

Thanks again for your honesty...

Before you read this please remember that I am NOT an insurance expert!! I'm just going by what some of our patients have dealt with regarding general insurance issues, I don't work in the field of bariatrics so I'm not referring to bariatric patients.

Diabetes vs. pre-diabetes. I have two friends that have been banded and they are both pre-diabetes. One has PCOS. Insurance required full blown diabetes in order to be a comorbidity. BTW, they were both self pay for their bands.

If you get an official diagnoses of pre-diabetes and let's say you don't get approval for the band because it isn't full blown diabetes, will this diagnosis now exclude you from getting coverage at a later time for a future insurance? This would be a question for Alexandra. I don't know the laws regarding this.

What are your fasting blood sugars? That is more what insurance is going to be looking at along with the comparison after you eat something.

We had a patient a long time ago that suffered from Munchausen Sydrome. She would fake illnesses in order to get the attention from diagnosis and treatment. She would come in NOT fasting for a blood sugar test and she came back mildly high. Then we'd have her drink glucose and her blood sugar did not reflect the additional sugar. In her case it was easy to demonstrate what she was doing for a variety of reasons. Point being, pre-bandsters get pretty anxious about getting the band and they do all kinds of strange things such as gaining weight to meet a required BMI, etc. Don't try to fool anyone with your blood sugars because it won't work. We need to find another way.

I doubt anyone will do anything other than to tell you to watch your diet, watch your caloric intake, and exercise for any blood sugars below 200 after food.

I can't see how hormonal issues would be a band issue. You would likely have those same issues as a thin person.

Reflux... you might have something here. You have to demonstrate that you have it but the more important issue is why. If you have a hiatal hernia THAT is something you can work with. Many obese people have them as often times obesity causes them. The key here is that if you do have a hiatal hernia you can have insurance pay for the OR, anesthesia, etc. to repair the hernia and then self pay for the band itself. The incisions for a hernia repair and the band are exactly the same. Most docs will fix a hernia while the place the band. See what I'm talking about? Let insurance pay for everything but the band itself. You may have to self pay for the band and the additional doc time to place the band. Much cheaper than paying for all of it. However, the band is $2K in Mexico and an OR person was just posting yesterday that the US cost for a band is $4K. Then surgeon fees on top of that.

Sleep apnea... just waking up a few times isn't sleep apnea. But you could try to get insurance to pay for a sleep study to see if anything is there.

Joint pain... you'd have to demonstrate on xray this is weight related. Do you have arthritis? Degenerative joint disease?

Honestly, I'm not seeing how you would possibly meet the requirements for insurance to pay for banding.

Anything under 200 is not a concern when it comes to comorbidities and WLS.

I disagree. Anytime your sugars are consistently out of range, it is a cause for concerne. LMJ needs to have her bloodwork done and find out her A1C. If she's 6.0 or higher, it's a comorbidity and if she has hypertension as well, she should be covered.

I have a past history of gestational diabetes, preecclampsia, infertility, suspected PCOS, and hpertension. I also have back/hip/feet pain (which I have never seen the Dr for but have had problems for years), abnormal or absent periods and I think my blood sugar is out of whack...Thank you!

Hi Michelle. I have PCOS and my surgeon said that was very important in getting my insurance to approve...so you may want to see about getting treated for that...my doc (GYN) prescribed glucophage (which I've since stopped) and birth control pills.

Just an idea...