Doing my research... could I be approved?

[haliib 9]

Hello! I am new to this site. I just started researching options for WLS a few days ago, and I have a few general questions I feel like I should get answered before I get my hopes up for anything.

(I understand that this is just a forum, and people are giving me opinions based on their experiences.)

I am 23 years old, and 250 lbs. My BMI is 41.

I have been obese since I turned 16 and started working at a fast food restaurant. I have been trying to lose weight since then. My pattern tends to be that I do really well for a few weeks and then I fall off the wagon once that initial motivation is gone and gain back even more weight.

My questions are as follows:

1) I have never done a medically supervised weight loss program. ( I have done Weight Watchers and similar programs). Will they want me to try a medically supervised program before considering me?

2) I have no co-morbidities, but diabetes, heart disease, and hypertension runs very strongly in my family. Could that be a reason to deny me?

Thank you for any responses you can give me, I appreciate any and all opinions and experiences. If these questions are more suited for a surgeon please let me know.

Thanks!

[Bufflehead 6,358]

It really depends on your insurance policy. You need to get your hands/eyes on the "plan document" or "member benefit handbook" and read about bariatric surgery under your specific plan.

Assuming your plan covers bariatric surgery -- and that is a big assumption -- the most typical policy rule is that you only need co-morbidities such as high blood pressure or diabetes with a BMI under 40. So, don't lose any weight before your initial consult with a surgeon!

Your plan may require you to have 3 or 6 months of supervised weight loss or dietary counseling before your surgery, but that will fly by before you know it.

You definitely want to get your plan documents and make an appointment with a bariatric surgery center of excellence for an initial consult. They should have an insurance coordinator on staff who will be knowledgeable about requirements.

This is all on the assumption that you are planning to use an insurance policy to pay rather than self-pay. If you are paying for this out of your own pocket, you will have no trouble finding a great surgeon to work with you. Good luck!

[duckydoom 128]

as @@Bufflehead said, it really depends on your insurance coverage.

For example - my plan covers bariatric surgery and is based on Medicare guidelines. This means with a BMI of 35-39.9 I would need at least one comorbidity from the list. With a BMI over 40 (which I now have), there are no comorbidities needed to qualify me, I just have to complete the other requirements of a nutrition evaluation and a psych eval and then we can submit to my insurance for authorization. They still have the final word of course, but they base it on the Medicare standards. I am trying to get my surgery done before the end of the year when we are set to change to Kaiser, because they have additional classes and requirements to be approved.

I have a friend who is looking at the surgery, and her plan excludes anything related to bariatric surgery, even if it will help alleviate other life threatening conditions, and it specifically calls that out. In her situation, we are looking at grants through WLSFA to see if we can have her approved there - to do that you need a referral/recommendation from a surgeon at a certified bariatric center of excellence, and luckily we have one local to us.

Of course there is always Mexico, and from what I understand (which is very limited, I haven't looked as I am trying my insurance first) they don't really have the BMI limitations that insurance companies do. If you have serious health issues that would prevent you from safely undergoing the surgery, any surgeon would want to resolve that prior to even considering it. Family history doesn't guarantee that you'll have the issues, so if you don't have them now it (in theory) shouldn't be an issue.

Definitely talk to your insurance though, get to know your coverage! Then get an appointment with a surgeon and talk to them about your health concerns and see if you are even a candidate to be approved at this point.

Good luck!

[KristenLe 5,980]

@@haliib Most insurance plans will cover surgery with a BMI over 40 (even if no comorbidities). The requirements of each plan can be different - so that will be specific to your plan (if you need a supervised weight loss program). I would call your insurance and get coverage details and find a surgeon who is part of a Center of Excellence. You often have to attend an informational seminar at the surgeon's office before scheduling an appointment. I think it's great you're getting control of your obesity now - before you have comorbidities to deal with! Good luck!

[Frenchie1977 262]

If your like me and you can't wait just call the number on the back of your insurance card, my insurance was clueless when I asked if Bariatric surgery was covered but they were able to look it up when I said sleeve gastrectomy. Now my insurance plan is different, it doesn't require any medically supervised weight loss but it doesn't cover unless you have a comorbidity, so I'm glad I checked with them before I even asked my doctor for a referral to the surgeon. Just give your insurance a call, it's easier than hunting down the insurance plan info. Best of luck

[KristenLe 5,980]

@@Albert Barret This is a surgical practice/hospital in Mexico. There's no need to contact them unless her insurance doesn't cover it and she plans on going to Mexico for self-pay. With a BMI of 41 - it's doubtful she'll need to self-pay.

[ella37 455]

I'm just curious for people who went through insurance. If your BMI is close to 40 and you go on the supervised diet, what happens if you lose enough so that it drops below 40?

[KristenLe 5,980]

@ It depends on the insurance - some take the original starting weight/BMI. But - in many cases you have to be careful and it's a juggling act - lose weight, don't lose too much weight, etc. The surgeon's insurance coordinator usually helps to determine where you need to be and if you can lose weight or not based on your insurance requirements.

[ella37 455]

@ It depends on the insurance - some take the original starting weight/BMI. But - in many cases you have to be careful and it's a juggling act - lose weight, don't lose too much weight, etc. The surgeon's insurance coordinator usually helps to determine where you need to be and if you can lose weight or not based on your insurance requirements.

That's so annoying. I think most of us know how to lose weight, we just keep gaining it back. So it can basically end up being a 6 month diet where you try to not lose anything, ugh. I hate the way insurance companies interfere with doctor's opinions.

[Bufflehead 6,358]

@ my insurance required me to do a 6 month supervised weight loss program and fail at losing weight, I guess to prove that I really do need the surgery and am incapable of losing weight without it. Well, I had been obese my entire life (at least since toddlerhood) and am quite the expert at failing to lose weight. I know exactly how to do that. My six month "test" was not very challenging, let's just say.

[lexiemustang 268]

I'm just curious for people who went through insurance. If your BMI is close to 40 and you go on the supervised diet, what happens if you lose enough so that it drops below 40?

When I was approved for surgery - my BMI was a 37.x.

The day of surgery, my BMI was a 34.1 - which means I dropped below the 35 BMI with two comorbidity cutoff. I was informed by my surgeon that my insurance goes by the BMI I was approved at - not the BMI I had during the day of surgery.

(Just as an FYI - I had United Healthcare at the time. I did not have to do a supervised diet as a part of the insurance requirements, but my doctor required a 2 week liquid diet prior to surgery).

[heidikat72 935]

And my insurance plan required I not gain even a pound during my 6 month supervised period. I didn't have to lose but I could not gain from one appointment to the next or the 6 month clock would start over.

I'll just offer up that even if your plan requires a 3 or 6 month supervised period - don't fret about it. I was upset at first but honestly I needed that time to get all the pre-op testing done and learn as much as possible and really truly prepare myself for post-op life. And it seriously went by faster than i could have imagined!

[Brenda Sherwood 64]

As others stated, it depends on insurance. I just got denied for the 2nd time even though I have a BMI of 46, high blood pressure, high cholesterol, pre diabetic and family histoty of every problem possible. But I have Amerigroup, who wants you to have what they consisder a disabling condition. The diet isnt necessarily a diet, its meeting withthe surgeon and a nutricianist regularly. I thought it was stupid at first too but I dont think anyone should get surgery without doing that now. It helps you prepare for life after surgery and understand what should and shouldnt be going in your body. I was very well educated in nutrician before this and still learned some stuff. Things I see people post on here that they are doing/trying to eat are crazy and show me that those individuals didnt see a nutricianist or didnt listen to anything. All insurance compnies will make you go through a lot of testing and such prior. It costs them anout 60,000 for your surgery so they want to make sure you are going to do the work required

Sent from my SM-G900P using the BariatricPal App

Edited August 18, 2016 by Brenda Sherwood

[DaisyAmy 561]

If you had my insurance , you would be approved after a six month medically supervised diet program.

The six months really is not a big deal. You'll need to have a bunch of tests run anyways, which takes time and I found that time to be great for learning a new lifestyle. I lost 60 pounds during my 6 months (actually took me 11 months to get there due to a little cancer delay).

Best of luck on your journey!