Fed BCBS, BMI 38/39, None of the top 4 comorbidities for insurance approval

[HopefulInVirginia 44]

Hi everyone. I am new to this forum. I am actually new to this journey. I have finally accepted that I cannot control my weight on my own and am in the process of checking off the boxes for insurance approval to have the gastric sleeve. My main concern at this point is that I will be denied by insurance. My BMI is 38/39. But I do not have sleep apnea, COPD, diabetes or hypertension. I do have osteoarthritis in at least one knee, scoliosis, GERD, prehypertension, and fatty liver disease. Can anyone with a bmi in this range and none of the top 4 major comorbidities share your stories with me, whether approved or denied? I would be especially interested in any experiences with Fed BCBS. Thanks in advance.

[jane13 2,256]

@@HopefulInVirginia - I cannot answer that particularly because I had a BMI over 40, plus other comorbidities.

I do have BCBS Fed employees.

Quick questions:

Have you weighed in at a doctors office yet for an official weight? If not ask your doctors office what the requirement is for your height. I would wear heavy jeans, socks, jewelry and maybe an over shirt to help nudge the scale if needed.

Are you 5'4"? I ask because most of us tend to bump up to the next inch and if you are actually 5'3" your BMI may be a bit higher. And unfortunately as we age we tend to shrink

I was a little worried and was told they could have listed me at 5'7" because I am just under 5'8". You are also shorter as the day wears on and taller in the morning...

[Read2016 658]

I agree with this, sadly this is what we're forced to do to get the treatment we need... I would suggest filling a change purse with coins and putting in your pocket. Along with cell phone etc... I haven't been denied yet but in several conversation with the insurance I can't get a clear answer regarding their requirements... What they say on the phone is more involved than what is in writing....

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[HopefulInVirginia 44]

Thanks for the responses. I was told at my initial meeting with the surgeon that even if my bmi was currently 40 or more, I would need a 2 year history of that bmi. Otherwise, if my bmi was under 40 for the last 2 years, I'd need to show comorbidities. While I would be willing to get my weight up to a bmi of 40 for a week, month, etc to qualify for coverage, I wouldn't do it for 2 years nor do I want to wait 2 years. This is so tough. I know that I cannot do this on my own and I know that I could be successful with this tool. I understand there have to be requirements but I hope the insurance company is willing to consider the entire picture, i.e. my literally thousands of failed attempts and the fact that every single person in my family including parents, sister, brother, aunts, uncles, cousins, etc is obese. Not just 20 or 30 pounds overweight but clinically obese ????

[Miss Mac 6,262]

This is a list of the many many comorbidities that are recognized by the U S Dept of Health and Human Services. I don't know why you were told that only the top four qualify. I am also attaching an edited copy of a letter I submitted to BCBS Federal that was included with the packet from the bariatric surgeon. Use it for inspiration if you need to. By the way, I claimed 20 of those comorbidities with a 40.6 BMI. I am retired V. A. My packet was submitted on a Thursday and approved that next Monday. BCBS approved a five-day stay although only two days were needed.

http://www.dsfacts.com/qualifying-for-weight-loss-surgery.php

Obesity Comorbidities

To follow is a list of comorbidities (additional conditions or diseases) related to obesity which may help you in qualifying for weight loss surgery.

• Family history of heart disease
• Family history of stroke

Family history of diabetes Family history of heart attacks Hyperinsulinemia Diabetes High blood pressure Coronary-artery disease Hypertension Migraines or headaches directly related to obesity or cranial hypertension Congestive heart failure Neoplasia Dyslipidemia Anemia Gallbladder disease Osteoarthritis Degenerative arthritis Degenerative disc Degenerative joint disease Recommended joint replacement from specialist Accelerated degenerative joint disease Asthma Repeated pneumonia Repeated pleurisy Repeated bronchitis Lung restriction Gastroesophageal reflex (GERD) Excess facial & body hair (Hirsutism) Rashes Chronic skin infections Excess sweating Frequent yeast infections Urinary stress incontinence Menstrual irregularity Hormonal abnormalities Polycystic ovaries Infertility Carcinoma (breast, colon, uterine cancer) sleep apnea Pseudotumor cerebri Depression Psychological/sexual dysfunction Social discrimination Premature death

Copy of REQUEST FOR APPROVAL FOR WEIGHT LOSS SURGERY.docx

[HopefulInVirginia 44]

Thank you! This is very helpful! And congrats on your successful journey. Hope I get to join you some day soon

[KristenLe 5,980]

Obesity Action Coalition has some great info about appealing. Get a letter from your PCP too.

[Read2016 658]

Thanks for the responses. I was told at my initial meeting with the surgeon that even if my bmi was currently 40 or more, I would need a 2 year history of that bmi. Otherwise, if my bmi was under 40 for the last 2 years, I'd need to show comorbidities. While I would be willing to get my weight up to a bmi of 40 for a week, month, etc to qualify for coverage, I wouldn't do it for 2 years nor do I want to wait 2 years. This is so tough. I know that I cannot do this on my own and I know that I could be successful with this tool. I understand there have to be requirements but I hope the insurance company is willing to consider the entire picture, i.e. my literally thousands of failed attempts and the fact that every single person in my family including parents, sister, brother, aunts, uncles, cousins, etc is obese. Not just 20 or 30 pounds overweight but clinically obese

I feel these "requirements" are driven by money rather than medical research.

I agree with appealing, don't accept no for an answer.

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[Acceber12 5]

Thank you for sharing, @@Miss Mac! I also have Federal BCBS, and am anxious about not having the requisite BMI of 40 or any co-morbities. I have my first consult with the surgeon on Monday, so hopefully I will have more information then. I did have gallbladder disease, but I had it removed earlier this year so I'm not sure if that counts anymore...

[KristenLe 5,980]

@@Acceber12 You may want to have them measure your height. Others are finding that they are actually an inch shorter than they always thought. That would bump your BMI up a little bit. Although - if you're already over 40 (even slightly) - you shouldn't have any problems getting approved (as long as you've been above 40 for a while (I think 2 years was my plan's requirement.

[Acceber12 5]

My plan is also 2 years. I had an appointment in December 2014, where I weighed in at 220. But since then I've gone down to 196 and then back up to 205, 210, and now most recently back up to 220 again. I'm hopeful that the December 2014 weigh in counts even though my BMI has gone below 40 since then!

[MeFirst 65]

I have BCBS Fed and was approved within a week of submission a couple months ago.

In my experience, your BMI must be 40 or higher on your initial weigh in with surgeon. Wear heavy clothes, stuff your pockets, etc.... The 2 year weight history has to be an obese weight history (over 35 BMI). As long as you have a weight for each year for the past 2 years that is above BMI 35, you should be fine.

I had no comorbidities, a BMI of barely 40 at first weigh in (thanks to a full bladder, keys, cellphones, jeans. Lol), and an over 35 BMI for the prior 2 years.

Good Luck!!!