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Unsure if I qualify - doing all the requirements but no co-morbidities



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Hey everyone!

I am currently in a 3 month program at an in-network hospital to do my surgery.They accept my insurance but as I am reading over the rider it states this as meeting requirements to be qualified:

"To be eligible to begin the qualification process You must be an adult age 18 or over, a non tobacco user and have a documented medical history of two years or more of a Body Mass Index (BMI):

 Equal to 35 and less than 40 with two or more co-morbid conditions

 40 or over with one or more co-morbid conditions"

under the definitions tab they have this as a co-morbidity:

"Co-morbid conditions: Means for the purposes of the Bariatric Surgery benefit, the following chronic health conditions:  Cardiomyopathy  Type 2 Diabetes  Coronary Heart Disease  Hypertension  Gastroesophageal reflux disease (GERD)  Clinically significant obstructive sleep apnea"

I am afraid that since I do not have any of those conditions I will not get approval for my surgery. My mother's side of the family has a history of diabetes while my father's side has a history of heart disease and cholesterol.

I am doing so well when it comes to getting all the proper requirements for my insurance. I'm getting a bariatric psych eval next week as well as finishing up my last month of classes at the hospital. Does it seem hopeful? Thank you!

Clarifications: I have Blue Cross Blue Shield of Kansas and this is my rider: https://www.bcbsks.com/CustomerService/Members/State/pdf/2018_BCBS_PLAN_C.pdf

Current weight: 285 BMI: 46

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With a BMIof 46 it would not be impossible to have either GERD or Apnea, what did your EGD show? And if you had a pulmonologist visit, did they check you for apnea too? Anything on your cardiology study? I mention these 3 "tigers in the jungle" because they run on both sides of my family, and doggone if I don't have signs of 2. And some insurances take secondary comorbities. One of my friends sqeaked through because of strong diabetic history made her in imminate danger because of her prediabetic condition. She had multiple over 8-9 lb babies who were technically early for estimated date and with last she had gestational diabetes. Talk with your PCP because they usually know you best, there might be a way medically to get around or even bend insurance rules. Some days you have to beat Big Insurance at their own games. Best to you in this struggle[emoji12]

Sent from my VS880PP using BariatricPal mobile app

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10 hours ago, Jumanna said:

 40 or over with one or more co-morbid conditions"

under the definitions tab they have this as a co-morbidity:

"Co-morbid conditions: Means for the purposes of the Bariatric Surgery benefit, the following chronic health conditions:  Cardiomyopathy  Type 2 Diabetes  Coronary Heart Disease  Hypertension  Gastroesophageal reflux disease (GERD)  Clinically significant obstructive sleep apnea"

I am afraid that since I do not have any of those conditions I will not get approval for my surgery. My mother's side of the family has a history of diabetes while my father's side has a history of heart disease and cholesterol.

Current weight: 285 BMI: 46

You're not being treated for high blood pressure (hypertension)? With a BMI of 46, you'd only need to meet one.

If you don't meet their criteria it is likely you won't be approved. Have you talked with your Dr, they may have a plan when submitting for approval.

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27 minutes ago, shelleycakes said:

You're not being treated for high blood pressure (hypertension)? With a BMI of 46, you'd only need to meet one.

If you don't meet their criteria it is likely you won't be approved. Have you talked with your Dr, they may have a plan when submitting for approval.

I am on and off with having high blood pressure, some days it's good and other days it's high. Overall it's not that severe. when i saw my doctor he just gave me an 'okay' to do surgery, didnt go too into detail about other comorbidities. i took and cholesterol test and lipid panel and my numbers were pretty normal. my main issue is how obese I am and heart disease/diabetes running in my family. idk what else to do but i really need this surgery and want to avoid getting denied.

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Go see your PCP and tell him your concerned you have sleep apnea because your tired all day and snore super loud. Ask for a sleep study. Most overweight people have it to some degree, there’s your co-morbidity


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I am on and off with having high blood pressure, some days it's good and other days it's high. Overall it's not that severe. when i saw my doctor he just gave me an 'okay' to do surgery, didnt go too into detail about other comorbidities. i took and cholesterol test and lipid panel and my numbers were pretty normal. my main issue is how obese I am and heart disease/diabetes running in my family. idk what else to do but i really need this surgery and want to avoid getting denied.

I have a BMI of 46 and the only other co-morbidity I have is Hypertension that’s being controlled with meds. My surgery was just approved. So if you’re at least on meds for the HTN and a BMI of 46 you shouldn’t have a problem.


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