weight used for approval

[ccol625 14]

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.

[bikrchk 1,313]

My process was:

6 month dr assisted diet (collect 6 sheets from 6 visits)

Psych consult

Nut consult

THEN I met with the surgeon for consult, submission to insurance etc. They took all the completed documentation above along with the recommendation from my PCP, docs on co-morbidities, etc and submitted me at my weight that day.

Approval took less than 2 weeks after which my EGD, blood work, pre-anesthesia and last pre-op with the surgeon and surgery was scheduled.

Once submitted the rest of the process took about 6 weeks.

I was close, with a BMI of about 36 the day I was submitted. (35 WITH co-morbs was the cutoff for my insurance). I weighed with my boots and coat ON. I'd have loaded rolls of quarters in my pockets if necessary!

[ccol625 14]

@@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.

[bikrchk 1,313]

@@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.

It DOES suck! Funny thing... I was in the Dr's office ALL THE DAMN TIME pre-op. I was either sick, or had to be monitored for all the meds I was taking. Just saw my doc today for the first time in a YEAR, (strep, can't dodge all the bullets apparently), I take no more perscriptions other then my PPI now so I'm living proof that medical costs GO DOWN when you reach a healthy weight. Pisses me off that they make us jump through so many hoops to get healthy! Hang in there. Some co-morbidities are "harder" than others. A history of high bp\cholesterol etc even on medication is harder to argue with than say, arthritis as there are no labs to prove it and degeneration takes time to show on an x ray. Bury them with documentation. And there's always quarters... In yer pockets and weighing with your boots on.

[Rovobay 920]

leaded pockets at weigh in!?!?!?! heavy boots? more...

[ccol625 14]

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. :-(

[scoutmom 63]

@@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.

Hi ccol625,

Which BCBS program do you have? My surgeons' office seems to think I will be fine for approval, but I have a BMI of 37 and my sleep study came back negative. So I am very nervous about getting approved. I have BCBS Federal.

[ccol625 14]

@@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

[scoutmom 63]

@@ccol625, I have been careful not to lose any weight so my BMI stays as high as possible. My insurance coordinator did not say anything about BCBS wanting me to lost weight during the 3 month waiting period.

If we gain to automatically be at 40 BMI do they automatically approve?

Any news on your appeal?

S

[AquariusDiva 15]

It appears to me that they go off your weight at the surgeons office. I was in a similar boat border line 38.5-39 most if my adult life. But I manAged to gain 10 lbs to make it over the 40 bmi.

From my experience with the 6 months NUT- I ended up gaining (but I also had a knee injury during that time). My husband has gone both up and down during his visits. For him the problem was that his PCP did not write very good notes about diet/exercise during his visits (just looked like normal co morbidity visits). We are still waiting on his approval.

Edited March 11, 2015 by AquariusDiva

[taweedeegirl 68]

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. :-(

I don't get what happened??

did u lose too much weight?

I'm currently trying to gain weight to reach a BMI of 40 ..to make sure I qualify for a starting weight.. then lose the weight during the process by eating " better"

[ccol625 14]

@@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.

[mykdzmom 387]

@ccol625 I hope you are approved. The process is nerve racking to say the least. I am in my 6 month pre op right now and this is always on my mind because of my BMI being so close to the requirement. Just wanted to say good luck!

[bncbabe2015 11]

My BMI is over 40, but borderline, so I'm scared if I lose on the 6 month diet like I would hope to, and fall below 40, that I will get denied and this will have all been for nothing! I have my initial consult with my surgeon tomorrow evening and I hope they can clarify which weight will ACTUALLY be used for approval. I have Anthem BCBS, anyone experienced anything with this?

[wildflowergirl 23]

I have to have a BMI of 40 for two years (in dr records) before my insurance will pay (I have Aetna) or 35 BMI with co-morbidities for two years.

I was just under 40 BMI with no co-morbidities for the last 3 years and was denied ( and yes I did appeal and was denied) .

Now I am at 40 BMI and have sleep apnea since November 2014 so in two years I can apply again.