Soooo...my BMI is 40, and I dropped a bit of weight, and got weighed at a scope procedure, and it was under the 40 BMI.....My question is this, does anyone know if you need to stay over 40 to qualify ? Or do they generally go by that initial weight? For the group I am using, you need to go to several support groups, meet w the nutritionist, etc....and in 3 mos from initial appointment you can get the surgery.

I am concerned about not being covered, if my wieghts show a BMI that varies from 40-30~something. Do I need to hit up Dunkin Donuts to stay fat enough for the 3 months? I have a sleep study coming up, and I am hoping I have obstructive sleep apnea, so I will be covered at a BMI of 35 and up with an added comorbidity.

I'd like to not need to stay "fat enough" but I need the Insurance coverage, and I am very worried that I am too close to the "cusp" of that 40 BMI, and it is really stressing me out.....soooo...any insight and experience would help. Of course I will ask at the appointments too, but I do not want to sound like I am avoiding Nutritionist advice, in order to stay "fat enough" to be covered.

Thanx!!!

* This was also posted in support, but then I saw this Insurance section and figured it might be better over here :-)

I have fepblue and it would have disqualified me to drop below 35 as , if I didn't have comorbidities.

But, I think if you have sleep apnea, you might be OK.

But, all insurance is different. I was 35.6 when I started and couldn't even lose 2 lbs or I would be not covered. That's hard! So I went self pay because it felt stupid to keep gorging to keep my weight up.

But many others say your initial bmi is what counts.

Good luck!

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Who is your carrier?

My insurance didn't seem too concerned with anything other than me having a 35 or over BMI with co-morbities for the previous 2 years.

Blue Cross. I do not have recorded weights at my Primary....I always said No to the scale....you know, denial.....

I hate to say it but i am really hoping I am dx with obstr sleep apnea!!!

1 hour ago, ToSleeveOrNotToSleeve said:

I have fepblue and it would have disqualified me to drop below 35 as , if I didn't have comorbidities.

But, I think if you have sleep apnea, you might be OK.

But, all insurance is different. I was 35.6 when I started and couldn't even lose 2 lbs or I would be not covered. That's hard! So I went self pay because it felt stupid to keep gorging to keep my weight up.

But many others say your initial bmi is what counts.

Good luck!

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How much was your selfpay, if you don't mind me asking....around here, eastern PA, I am prett sure it'd be like 18,000

25 minutes ago, ProfessorSlim said:

How much was your selfpay, if you don't mind me asking....around here, eastern PA, I am prett sure it'd be like 18,000

$8899, included surgeon and 2 nights in the hospital. $500 for 5 nights hotel, $200ish for preop testing through my Pcp blood work, ekg, chest xray and a psych eval. But depending on age/situation, they've been known to waive certain tests such as psych and h pylori. Plus gas money.

We stayed at a nicer hotel. Hubby likes Marriott and free breakfast! We left 2 days early to make the drive easier, so we probably could have saved a night's hotel had we wanted to push it. There is a LA Quinta within walking distance most people stay at and are happy with.

There were plenty of cheap flights into ft lauderdale and Miami, but we chose to drive the 8 hours.

I used bariatrix Florida, Dr amit Taggar. Couldn't be happier. Turnaround time was like 3 weeks from consult to surgery.

Depends on your insurance. I have Regence BCBS Oregon and their policy is "bmi above 40 at the START of medically supervised blah blah blah"...BUT it's best Togo thru your pre-op process in the minds of insurance claims administrators. Unfortunately, their goal is to make money-not give it away. So their main objective when determining medical necessity is finding ANY REASON to deny you. Sure, they have the policy and you can check every box, but they may or may not deny based on that one weigh in that dips below 40 bmi. This is where you'll want appeal...most insurance companies bank on denials over small details like that hoping you won't appeal but if you do you'll most likely get it. Hope this helps!

I'm in a similar situation. BMI is 40.6 I have co morbidities but my previous doctor didn't like officially diagnosing me. She said I had asthma when I was 12. Depression at 13. GERD at 15. Gastritis at 17. Ulcer at 19. Diabetes at 21. Now I'm 22 switching doctors and according to my health records. I was never diagnosed with anything other than mental health thanks to my therapist.

The only co morbiditirs my insurances allows with BMI under 40 are diabetes and hypertension (or life threatening cardio problems)

So I have to say "I hope I have diabetes" otherwise I'm screwed on surgery.

My nutritionalist was very serious when she told me I could lose 12 lbs - NO MORE!!!

You and I are in the same boat. I can't lose anything or I won't be covered (Less than 5lbs over the next 6 months). I hate it because I want to make the most of my dietician visits that I'm having to pay for out of pocket but if I do, i'll disqualify myself. I have Tricare reserve select. [emoji53]

I have my appointment tomorrow, hopefully to see if they are ready to submit to insurance.....fingers crossed!!