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BMI too low for insurance to cover surgery



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Well, today was weird. On the one hand, I am thrilled to be moving forward with pursuing gastric sleeve. I'm thrilled that apparently I don't have to wait six months before I can even schedule surgery.

And why is that?

I found out that my insurance company will not cover my surgery because my BMI is 37 and it needs to be 40, minimum, for them to cover it, unless I have other co-morbidity health issues, which I do not.

I thought that having PCOS and asthma would be enough, but they aren't. It's weird to be pursing something for my health and told I am "unhealthy" enough to get the surgery and be a good candidate for it, but not "unhealthy" enough to have my insurance pay for it. So now we're looking at getting a home equity loan to cover the $16,000 cost, which is due up front. It's a weird feeling. I guess I could gain the 25 lbs needed to qualify, and then go through the 6 month prep period my insurance requires, but that all seems very counterintuitive to why I'm on this journey -- which is to be healthier. So I think I'm just going to go into a bit of debt and do it.

Have you ever heard of this type of situation happening? It's totally weird, isn't it!

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I work for the state and have Public Employee Insurance. They find ANYTHING they can not to pay for the surgery. With me they turned me down because I take thyroid medication. Lots if reasons they deny, if a person has ever taken an antidepressant is another reason they will deny the surgery.

It worked out for the best, the surgeon I chose in Las Vegas charges $5500 all inclusive. I had sleeve and hiatal hernia repair done at the same time. They billed my insurance for the hernia repair and that's how the surgeon got paid. My out of pocket was $5500. He has his own surgery center and I had it done outpatient. I never had any symptoms of hiatal hernia but the surgeon said almost everyone that is overweight has one. Everything went well and Im grateful I found my surgeon.

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Have you thought about Mexico? a lot of people on here save a great deal of money by going there for their surgery.

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Did you get a sleep study for sleep apnea? Random, I know but that could be a qualifier.

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Did you get an EDG scope for a hernia? That might qualify you. I would gain some weight rather than risk my house, or do the travel for surgery to another state or Mexico. You could try the sleep apnea study, the EDG, gain some weight and put rolls of quarters in your jean pockets, weighin in jeans, heavy shoes and do the 6 months, honestly 6 months goes fast.

It would only be 21 pounds to 40 bmi.

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I'm not quite where you are in the process. What i mean is i haven't been denied yet. I've completed 3 months of my dietitian visits, i've had a sleep study, which i found i do have mild sleep apnea. My BMI is currently 37. I do have osteoarthritis in both knees. My surgeon is requesting a cardio clearance and an EGD since i had my lap-band slip back in '15. He wants to make sure all looks ok. I'm very scared i won't be approved. Every day i wait, i feel more and more sad about the whole process.

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On 8/7/2018 at 9:50 PM, Vegasurvivor said:

I work for the state and have Public Employee Insurance. They find ANYTHING they can not to pay for the surgery. With me they turned me down because I take thyroid medication. Lots if reasons they deny, if a person has ever taken an antidepressant is another reason they will deny the surgery.

It worked out for the best, the surgeon I chose in Las Vegas charges $5500 all inclusive. I had sleeve and hiatal hernia repair done at the same time. They billed my insurance for the hernia repair and that's how the surgeon got paid. My out of pocket was $5500. He has his own surgery center and I had it done outpatient. I never had any symptoms of hiatal hernia but the surgeon said almost everyone that is overweight has one. Everything went well and Im grateful I found my surgeon.

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I'm pretty sure this is the same place I just had mine done and I also had the sleeve and hh repair.

I live in Vegas but a lot of people travel here for the surgery.

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I know this sounds bad, or sneaky, but eat like **** for a couple weeks/months and gain a few pounds, put heavy weights on your wrists and ankles, go back in a month and get weighed and they’ll cover it. I know someone who did that. Worked like a charm and now they’re 6 weeks post op and down 50 pounds.

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I can't see gaining weight to qualify and not really knowing if for some other reason in the end you may not qualify. I would look for a different surgeon, they may have other ways to qualify you, such as hiatal Hermia or sleep apnea. Or self pay with a different surgeon at a lower cost.

Well, today was weird. On the one hand, I am thrilled to be moving forward with pursuing gastric sleeve. I'm thrilled that apparently I don't have to wait six months before I can even schedule surgery.
And why is that?
I found out that my insurance company will not cover my surgery because my BMI is 37 and it needs to be 40, minimum, for them to cover it, unless I have other co-morbidity health issues, which I do not.
I thought that having PCOS and asthma would be enough, but they aren't. It's weird to be pursing something for my health and told I am "unhealthy" enough to get the surgery and be a good candidate for it, but not "unhealthy" enough to have my insurance pay for it. So now we're looking at getting a home equity loan to cover the $16,000 cost, which is due up front. It's a weird feeling. I guess I could gain the 25 lbs needed to qualify, and then go through the 6 month prep period my insurance requires, but that all seems very counterintuitive to why I'm on this journey -- which is to be healthier. So I think I'm just going to go into a bit of debt and do it.
Have you ever heard of this type of situation happening? It's totally weird, isn't it!


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My insurance doesn't cover it period. (insert dramatic eye roll here) Because they say, "That is a surgery that is not deemed necessary and that is just for vanity/glamour and that even though my bmi is 40 and i have co-morbidity health issues (high blood pressure, thyroid, cholesterol issues) that I can just lose the weight. (sigh) so i'm doing mine oop next state over. I think its like $12k-$16k depending upon which surgery center I choose. I'm meeting with several different ones to see which one i like best. I'm having to finance mine as well. So i'm right in the boat with you. I hope yours goes well! Just sucks that insurance refuses to pay out for stuff when already we pay them so much a month to be covered just to be told no in the end. :(

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You can travel to Vegas and have sleeve for about $5500. They allow half up front and the other half interest free payments for one year.

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Forget eating - If you do not have co-morbidity factors then put fishing weights in your pockets next time that you go the Doctor. They are small and you can gain 10 pounds overnight

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Hello I was in the same boat as you, but my Pcp tried everything to see if I qualified. I already have hypertension but the surgeon office wants you to have 2 comorbidities. So I had a cholesterol test and a home sleep study done so my cholesterol over all cholesterol was elevated 232 and I have a mild sleep apnea , so I was able to get a visit with the surgeon just waiting for the call this week. So have your Dr. to put a sleep study in for you I didn't think I had it until I started to research it. And low and behold I did.

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@bunnygirl650 Keep me posted on your journey. My story is very similar to yours.

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My insurance company would only pay if BMI was UNDER 37. My BMI was 47 and I had 3 co-morbidities but they still would not pay. Makes no sense at all. My only thought was that it wanted to keep premiums down for our plan.

Do not exclude Mexico from your research and do noT listen to people who poo poo it unless they can back it up with facts (which they cannot). I have a friend who is a PhD/MD and agrees that For this particular surgery Mexico is better than than the US in terms of outcomes. You just have to research the doctors and talk to a lot of people. I had a great experience in Mexico. My dr even fixed my hiatal hernia that I didn’t even know I had. I have had zero complicAtions and am at 7 weeks out. The hospital was like staying in a 4 star hotel and was in a very safe and upscale area of Tijuana. Total bill was $8700 not including flight. Do yourself a favor and at least check it out.

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