Final clearance and Now I dont qualify!!

[ukeka22 4]

I am very upset /confused. At the start of this process, I was told that because my BMI is 44.14 my insurance (NY- Stright Medicaid -no ***/ppo) would approve with out having a comorbidity.

I have a history of elevated BP on and off... no concrete diagnosis of High BP, no other health issues. I completed my final clearance (endoscopy) this past Tuesday 8/29/17 all other clearances are done My new primary care doctor is waiting to clear me once he receives the endoscopy report. I have met with the nutritionist my required times, attended the monthly support group, quit smoking and now they tell me its unlikely to be approved! I am at my wits end! I have not had a sleep study and asked if they could send me for one to see if I can possibly be approved through this avenue.

I really don't know what to do? I have been 100% compliant feeling confused and discouraged

[trying4me 56]

What is there reasoning for saying you probably won't be approved?

And you should definitely get a sleep study.

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[Paigetherage 7]

Did you lose too much weight? I know with certain insurances and surgeons they want you to do a pre-op diet of about 6 months. If you lose too much (go under 40 BMI) during the 6 months then insurance might not approve you. Some insurance companies go by your start weight, but others want your whole journeys worth.

[ukeka22 4]

37 minutes ago, trying4me said:

What is there reasoning for saying you probably won't be approved?

And you should definitely get a sleep study.

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Surgical Coordinator says because there is nothing "Wrong" with me that is unlikely to be approved. She said she doesn't want to send me for a sleep study since I was already cleared by Pulmonary....

[trying4me 56]

Surgical Coordinator says because there is nothing "Wrong" with me that is unlikely to be approved. She said she doesn't want to send me for a sleep study since I was already cleared by Pulmonary....

I find it interesting that Pulmonary cleared you without a sleep study. I had NO symptoms of sleep apnea but my study showed I had severe apnea. Now I have CPAP.

I would also call you insurance and ask for their requirements.

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[Lannie 135]

It depends on the insurance but normally BMI over 40 does not require a comorbid diagnosis. It doesn't make sense to wait until "something is wrong". The weight alone is what is wrong. Unless you lost significant weight during pre-op you should still qualify. Call the insurance carrier to reconfirmed requirements

[readytorunagain 66]

The surgical coordinator shouldn't be the one to say if something is "wrong" with you. Get copies of what was submitted and find someone more compassionate to talk with at the insurance company. Tell your primary you are tired all day and don't get enough sleep. Tell them you are concerned you have apnea. Have your primary write you a script for an at home sleep study. Is your BMI still over 40? Are you prediabetic? Do you have high cholesterol or arthritis? Keep track of how you feel and keep following up. They will eventually clear you if you meet requirements.

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[AsianBeauty 78]

So the "coordinator" said it was unlikely for you to be approved. Sounds like to me she's not doing her job. A coordinator job is to help you stay on track with meeting your requirements fo r your insurance. Him/ her gathers all your paperwork work and submits it to your insurance company for approval. Your coordinator has no right to make a pre judgment on wether she THINKS you will be approved or not. Th e coordinator are not the ones who approves you for surgery. And you are correct as long as your BMI is o
40 or over uo u do not need any cormobilities. I would advise you just to let your coordinator know that you still want your information submitted to your insurance company and let them tell you that you are denied. And if you are you can ask questions. Ask them why a d what do you need to do to get approved. I would not accept what th e coordinator is telling you. Sometimes if you want something for you have to do it yourself. Everyone does not have your best interest at heart...... I wish you th e best of luck on your journey.

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[Mhy12784 423]

Doing a quick Google search the requirements for bariatric surgery with medicaid seems to be a bmi of 35 with a comorbidity (no mention of bmi over 40)

May just be a medicaid thing to control costs or whatever. I know people keep mentioning the bmi of 40 thing but medicaid typically has more strict criteria than commercial insurance

Of course I didn't see this on the official medicaid website as it's a pain to navigate , but it would explain why the OP may not be qualified without a cormorbidity

And if the OP doesn't have hypertension I have to imagine it being relatively unlikely that they suffer from severe OSA although if insurance covers the sleep study it's worth a shot.

Edited September 3, 2017 by Mhy12784

[amf1025 71]

I have Medicaid in NY and have a bmi over 40 and was approved ! If you are on blood pressure meds you will be approved

[ukeka22 4]

1 hour ago, amf1025 said:

I have Medicaid in NY and have a bmi over 40 and was approved ! If you are on blood pressure meds you will be approved

Thanks for your reply. I am not on BP medication.

[ukeka22 4]

8 hours ago, readytorunagain said:

The surgical coordinator shouldn't be the one to say if something is "wrong" with you. Get copies of what was submitted and find someone more compassionate to talk with at the insurance company. Tell your primary you are tired all day and don't get enough sleep. Tell them you are concerned you have apnea. Have your primary write you a script for an at home sleep study. Is your BMI still over 40? Are you prediabetic? Do you have high cholesterol or arthritis? Keep track of how you feel and keep following up. They will eventually clear you if you meet requirements.

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Thanks for your reply. I will try speaking with my PCP. I have high cholesterol, but that alone won't qualify for a comorbid as far as I know... I will ask though

[ukeka22 4]

9 hours ago, Paigetherage said:

Did you lose too much weight? I know with certain insurances and surgeons they want you to do a pre-op diet of about 6 months. If you lose too much (go under 40 BMI) during the 6 months then insurance might not approve you. Some insurance companies go by your start weight, but others want your whole journeys worth.

Thanks for your reply. I have only lost 6lbs, BMI Still over 40.

[Paigetherage 7]

You should still be eligible and approved then, just having a 40 BMI is enough to qualify you for bariatric surgery. Maybe you should try a different bariatric team. Seems the coordinator isn't taking in your best interest. Your team is supposed to be on YOUR side.

[Paigetherage 7]

Also want to mention my close friend who I am doing this journey with has Medicaid as well. Has no comorbidities and has a BMI over 40. She hasn't had any issues thus far with the coordinator saying she isn't qualified. I will let you know as it gets closer though. She's due for her RNY surgery on October 22nd.