Can bmi alone prove surgery is medically necessary?

[Tasia29 9]

Hi everyone,

I just have a quick question. My insurance's only requirement to have gastric bypass is that the surgery be medically necessary.

I do not have any health conditions because of my weight. I am in good health except for my weight. I do have issues with my gallbladder. Because of that my doctor plans to remove it at the same time during my gastric bypass surgery.

Will a bmi over 40 be enough to prove it's medically necessary?

I'm worried I might get denied by my insurance because I do not have any health conditions related to my weight.

Any and all replies welcome! Thanks!!

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[Creekimp13 5,837]

BMI over 40 and a letter from both your referring doctor and your surgeon should be good enough:)

[Tasia29 9]

Okay cool! I'm really stressing out about it. I want this surgery so bad!! [emoji4] I see my surgeon on the 25th. Hoping he'll submit my papers after the appointment. Not looking forward to the wait before hearing back from insurance lol!!

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[Gazebo 27]

I got my approval mainly by having a high BMI and being classified as morbidly obese. It still took me 8 months because of all the testing.

[Sadiebug 206]

My insurance will approve with a BMI over 40 with no other significant medical issues. BMI between 30-40 needs to also have a medical issue. My program did warn me ahead of time that if my BMI dropped below 40 during my pre-op phase I might have trouble getting approved - but there was no chance of that for me, my starting BMI was around 52.

[Tasia29 9]

I got my approval mainly by having a high BMI and being classified as morbidly obese. It still took me 8 months because of all the testing.

Okay. My bmi is in the 50s right now. I believe it was in the early 60's when I started the process.

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[Tasia29 9]

My insurance will approve with a BMI over 40 with no other significant medical issues. BMI between 30-40 needs to also have a medical issue. My program did warn me ahead of time that if my BMI dropped below 40 during my pre-op phase I might have trouble getting approved - but there was no chance of that for me, my starting BMI was around 52.

Okay. My bmi is in the 50s right now. I believe it was in the early 60's when I started the process.


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[KimTriesRNY 1,853]

You should be fine. My insurance was BMI of 35 with comorbid condition or a BMI above 40. There were of course all the other usual required tests for approval, six months medical visits psych evaluation, egd, etc.

[kdavis12508 2]

If ur not that big, why wouldn't you go with the sleeve?

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[Tasia29 9]

If ur not that big, why wouldn't you go with the sleeve?

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Because my surgeon feels I will get the best results with the gastric bypass.

[Tasia29 9]

You should be fine. My insurance was BMI of 35 with comorbid condition or a BMI above 40. There were of course all the other usual required tests for approval, six months medical visits psych evaluation, egd, etc.

Yeah I'm glad that I already completed all the tests needed and psych evaluation. I just have to attend my last supervised visit which will be on the 25th and meet with my surgeon. So excited but so nervous too!!! [emoji4]

[solo224 1]

My BMI was just barely at 40 with no co-morbidities and I got approved on first try through insurance. It was actually super easy too. Started the process with my bariatric surgeon in March and had approval by May 1st but had to wait until June 1st for an opening in the operating room. Guess it just depends on your surgeon's office and if they know the right things to say in that letter to get things pushed through. And of course how difficult your insurance is and whether or not they want to drag things out. It's definitely in their best interests to get the weight off of you and down to a healthy weight now BEFORE the co-morbidities set in, rather than to have you end up on a bunch of meds and possible major health issues that they'll be footing the bill for later.

[Chyna98 4]

My BMI was just barely at 40 with no co-morbidities and I got approved on first try through insurance. It was actually super easy too. Started the process with my bariatric surgeon in March and had approval by May 1st but had to wait until June 1st for an opening in the operating room. Guess it just depends on your surgeon's office and if they know the right things to say in that letter to get things pushed through. And of course how difficult your insurance is and whether or not they want to drag things out. It's definitely in their best interests to get the weight off of you and down to a healthy weight now BEFORE the co-morbidities set in, rather than to have you end up on a bunch of meds and possible major health issues that they'll be footing the bill for later.

What ins do you have? I have Aetna and go for my consultation on the 29th.

[pollymatin 6]

I wouldn’t have been able to have my surgery, I was diagnosed with sleep apnea, then I was approved.