Jump to content
×
Are you looking for the BariatricPal Store? Go now!

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



Recommended Posts

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

Share this post


Link to post
Share on other sites

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

Share this post


Link to post
Share on other sites

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.

Share this post


Link to post
Share on other sites

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.

Share this post


Link to post
Share on other sites

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


Share this post


Link to post
Share on other sites

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.


Share this post


Link to post
Share on other sites

Create an account or sign in to comment

You need to be a member in order to leave a comment

Create an account

Sign up for a new account in our community. It's easy!

Register a new account

Sign in

Already have an account? Sign in here.

Sign In Now

  • Trending Products

  • Trending Topics

  • Recent Status Updates

    • Prdgrdma

      So I guess after gastric bypass surgery, I cant eat flock chips because they are fried???  They sell them on here so I thought I could have them. So high in protein and no carbs.  They don't bother me at all.  Help. 
      · 1 reply
      1. NickelChip

        It's possible for a very high fat meal to cause dumping in some (30% or so) gastric bypass patients, although it's more likely to be triggered by high sugar, or by the high fat/high sugar combo (think ice cream, donuts). Dietitians will tell you to never do anything that isn't 100% healthy ever again. Realistically, you should aim for a good balance of protein, carbs, and fat each day. Should you eat fried foods every day? No. Is it possible they will make you sick? Maybe. Is it okay to eat some to see what happens and have them for a treat every now and again? Yes.

    • NovelTee

      I'm not at all hungry on this liquid pre-op diet, but I miss the sensation of chewing. It's been about two weeks––surgery is in two days––and I can't imagine how I'll feel a couple of weeks post-op. Tonight, I randomly stumbled upon a mukbang channel on YouTube, and it was strangely soothing... is it just me, or is this a thing? 
      · 1 reply
      1. NickelChip

        I actually watched cooking shows during my pre-op, like Great British Baking Show. It was a little bizarre, but didn't make me hungry. I think it was also soothing in a way.

    • Clueless_girl

      How do you figure out what your ideal weight should be? I've had a figure in my head for years, but after 3 mths of recovery I'm already almost there. So maybe my goal should be lower?
      · 3 replies
      1. NickelChip

        Well, there is actually a formula for "Ideal Body Weight" and you can use a calculator to figure it out for you. This one also does an adjusted weight for a person who starts out overweight or obese. https://www.mdcalc.com/calc/68/ideal-body-weight-adjusted-body-weight

        I would use that as a starting point, and then just see how you feel as you lose. How you look and feel is more important than a number.

      2. Clueless_girl

        I did find different calculators but I couldn't find any that accounted for body frame. But you're right, it is just a number. It was just disheartening to see that although I lost 60% of my excess weight, it's still not in the "normal/healthy" range..

      3. NickelChip

        I think it's important to remember that the weight charts and BMI ranges were developed a very long time ago and only intended to be applied to people who have never been overweight or obese. Those numbers aren't for us. When you are larger, especially for a long time, your body develops extra bone to support the weight. Your organs get a little bigger to handle the extra mass. Your entire infrastructure increases so you can support and function with the extra weight. That doesn't all go away just because you burn off the excess fat. If you still had a pair of jeans from your skinniest point in life and then lost weight to get to the exact number on the scale you were when those jeans fit you, chances are they would be a little baggy now because you would actually be thinner than you were, even though the scale and the BMI chart disagree. When in doubt, listen to the jeans, not the scale!

    • Aunty Mamo

      Tomorrow marks two weeks since surgery day and while I'm feeling remarkably well and going about just about every normal activity, I did wind up with a surface abscess on on of my incision sights and was put on an antibiotic that made me so impacted that it took me more than two hours to eliminate yesterday and scared the hell out of me. Now there's Miralax in all my beverages that aren't Smooth Move tea. I cannot experience that again. I shouldn't have to take Ativan to go to the lady's. I really looking forward to my body getting with the program again. 
      I'm in day three of the "puree" stage of eating and despite the strange textures, all of the savory flavors seem decadent. 
      I timed this surgery so that I'd be recovering during my spring break. That was a good plan. Today is a state holiday and the final day of break. I feel really strong to return to school tomorrow. 
      · 0 replies
      1. This update has no replies.
    • BeanitoDiego

      Now that I'm in maintenance mode, I'm getting a into a routine for my meals. Every day, I start out with 8-16 ounces of water, and then a proffee, which I have come to look forward to even the night before. My proffees are simply a black coffee with a protein powder added. There are three products that I cycle through: Premier Vanilla, Orgain Vanilla, and Dymatize Vanilla.
      For second breakfast on workdays, I will have a low-fat yogurt with two tablespoons of PBFit and two teaspoons of no sugar added dried cherries. I will have ingested 35-45 grams of protein at this point between the two breakfasts, with 250-285 calories, and about 20 carbs.
      For second breakfast on non-workdays, I will prepare two servings of plain, instant oatmeal with a tablespoon of an olive oil-based spread. This means I will have had 34 grams of protein, 365 calories, and 38 carbs. Non-workdays are when I am being very active with training sessions, so I allow myself more carbohydrate fuel.
      Snacks on any day are always mixed nuts, even when I am travelling. I will have 0.2 cups of a blend that I make myself. It consists of dry roasted peanuts, cashews, pumpkin seeds, sunflower seeds, pistachios, and Brazil nuts. This is 5 grams of protein, 163 calories, and 7 carbs.
      Breakfast and snacks have been the easiest to nail down. Lunch and dinner have more variables, and I prepare enough for leftovers. I concentrate on protein first, and then add vegetables. Typically tempeh, tofu, or Field Roast products with roasted or sautéed vegetables. Today, I will be eating leftovers from last night. Two ounces of tempeh with four ounces of roasted vegetables that consist of red and yellow sweet peppers, sweet potatoes, small purple potatoes, zucchini, and carrots. I will add a tablespoon of olive oil-based spread, break up 3 walnuts to sprinkle of top, and garnish with two tablespoons of grated Parmesan cheese. This particular meal will be 19 grams of protein, 377 calories, and 28 grams of carbs. Bear in mind that I do eat more carbs when I am not working, and I focus on ingesting healthy carbs instead of breads/crackers/chips/crisps.
      It's a helluva journey and I'm thankful to be on it!
       
      · 0 replies
      1. This update has no replies.
  • Recent Topics

  • Hot Products

  • Sign Up For
    Our Newsletter

    Follow us for the latest news
    and special product offers!
  • Together, we have lost...
      lbs

    PatchAid Vitamin Patches

    ×