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

Sleeve Surgery - BMI 38; Insurance Question



Recommended Posts

Hello everyone! New here. I’m hoping to get some helpful advice.

I personally have been struggling with my weight a lot of my adult life, but most seriously in the last 9-10 years since the birth of my youngest. Current weight is about 230 and height is 5’5. (Although I realize my primary doctor has me in the computer as 5’6). That puts my current BMI at 37-38.

I am seriously considering the gastric sleeve. I narrowed my initial research down to 2 surgeons. I live in the NYC area but am looking to have the surgery near Nassau county, Long Island. My insurance is Emblem Health/HIP for employees of the City of NY.

The obstacle I foresee is that I don’t know if I have qualifying co-morbidities, as far as the insurance is concerned. I had a physical in June, and per my bloodwork, I have high triglycerides, slightly high cholesterol, and am pre-diabetic.

I called the first surgeons office and the receptionist asked for my height and weight. Then she asked for any co-morbidities, and I mentioned the pre-diabetes. She shut me down right away and said that’s not enough, I would have to be diabetic and on medication. I mentioned to her that I am having an at home sleep study next week, she said to call back after I get those results. She didn’t even ask me what my insurance was, so I suppose this just the surgeons requirements.

Anyone have any idea about whether the high cholesterol/triglycerides would count as a co-morbidity for insurance approval? Or is the possible sleep apnea the only other thing that might qualify me at this point?

I was going to call the other surgeon I was considering, but this discouraged me a bit. If I am to do the surgery, I would love to do it sometime in the near future. I will be working from home for awhile due to COVID, so being able to do the next 6 months or so would be ideal. I also had an EKG done this summer, which came out OK, and I have recorded weights from doctors’ offices for June, July, and August. I think my insurance requires 6 months worth of documented weights.

Thanks in advance for any insight/advice.

Share this post


Link to post
Share on other sites

If the sleep study results show you have sleep apnea, that is a comorbity that will qualify you. the high cholesterol wouldn't count

Share this post


Link to post
Share on other sites

I guess it depends on the insurance, because high cholesterol is considered a co-morbidity with my insurance (BCBSTX). I had high blood pressure and high cholesterol and I got improved with a 32 BMI. First attempt too. I will say I had a long history of those - guess they were sick of dealing with it.

I was borderline diabetic too, but borderline definitely does NOT count. You have to be officially diagnosed with diabetes for it to count.

Have you read your policy requirements thoroughly?

I honestly did not think I would qualify but somehow I did? I'd wait until your sleep apnea test is completed and find out the results... and perhaps try another surgeon who would be more willing to help you.

Share this post


Link to post
Share on other sites

4 hours ago, Allienyc said:

Hello everyone! New here. I’m hoping to get some helpful advice.

I personally have been struggling with my weight a lot of my adult life, but most seriously in the last 9-10 years since the birth of my youngest. Current weight is about 230 and height is 5’5. (Although I realize my primary doctor has me in the computer as 5’6). That puts my current BMI at 37-38.

I am seriously considering the gastric sleeve. I narrowed my initial research down to 2 surgeons. I live in the NYC area but am looking to have the surgery near Nassau county, Long Island. My insurance is Emblem Health/HIP for employees of the City of NY.

The obstacle I foresee is that I don’t know if I have qualifying co-morbidities, as far as the insurance is concerned. I had a physical in June, and per my bloodwork, I have high triglycerides, slightly high cholesterol, and am pre-diabetic.

I called the first surgeons office and the receptionist asked for my height and weight. Then she asked for any co-morbidities, and I mentioned the pre-diabetes. She shut me down right away and said that’s not enough, I would have to be diabetic and on medication. I mentioned to her that I am having an at home sleep study next week, she said to call back after I get those results. She didn’t even ask me what my insurance was, so I suppose this just the surgeons requirements.

Anyone have any idea about whether the high cholesterol/triglycerides would count as a co-morbidity for insurance approval? Or is the possible sleep apnea the only other thing that might qualify me at this point?

I was going to call the other surgeon I was considering, but this discouraged me a bit. If I am to do the surgery, I would love to do it sometime in the near future. I will be working from home for awhile due to COVID, so being able to do the next 6 months or so would be ideal. I also had an EKG done this summer, which came out OK, and I have recorded weights from doctors’ offices for June, July, and August. I think my insurance requires 6 months worth of documented weights.

Thanks in advance for any insight/advice.

High blood pressure (diagnosis of hypertension), Sleep apnea , gerd (for bypass) but for my insurance at that low of bmi requires two comorbity

Share this post


Link to post
Share on other sites

I forgot to add that part in my post. Mine required two comorbidity as well.

I know that these were considered comorbidities: high blood pressure, high cholesterol, sleep apnea and diabetes.

Share this post


Link to post
Share on other sites

Thanks everyone. I believe my insurance only requires one Co-morbidity. Let’s see what the sleep study says. Doing a home one should be interesting. I wonder how accurate they are. Stay tuned!

Share this post


Link to post
Share on other sites

Hi, I had a BMI if 38 my insurance required a comorbidity that was being treated. I have high blood pressure and high cholesterol but was only taking medication for the high BP and that was enough for approval (BCBSMA).

Share this post


Link to post
Share on other sites

On 8/25/2020 at 12:59 PM, Allienyc said:

Hello everyone! New here. I’m hoping to get some helpful advice.

I personally have been struggling with my weight a lot of my adult life, but most seriously in the last 9-10 years since the birth of my youngest. Current weight is about 230 and height is 5’5. (Although I realize my primary doctor has me in the computer as 5’6). That puts my current BMI at 37-38.

I am seriously considering the gastric sleeve. I narrowed my initial research down to 2 surgeons. I live in the NYC area but am looking to have the surgery near Nassau county, Long Island. My insurance is Emblem Health/HIP for employees of the City of NY.

The obstacle I foresee is that I don’t know if I have qualifying co-morbidities, as far as the insurance is concerned. I had a physical in June, and per my bloodwork, I have high triglycerides, slightly high cholesterol, and am pre-diabetic.

I called the first surgeons office and the receptionist asked for my height and weight. Then she asked for any co-morbidities, and I mentioned the pre-diabetes. She shut me down right away and said that’s not enough, I would have to be diabetic and on medication. I mentioned to her that I am having an at home sleep study next week, she said to call back after I get those results. She didn’t even ask me what my insurance was, so I suppose this just the surgeons requirements.

Anyone have any idea about whether the high cholesterol/triglycerides would count as a co-morbidity for insurance approval? Or is the possible sleep apnea the only other thing that might qualify me at this point?

I was going to call the other surgeon I was considering, but this discouraged me a bit. If I am to do the surgery, I would love to do it sometime in the near future. I will be working from home for awhile due to COVID, so being able to do the next 6 months or so would be ideal. I also had an EKG done this summer, which came out OK, and I have recorded weights from doctors’ offices for June, July, and August. I think my insurance requires 6 months worth of documented weights.

Thanks in advance for any insight/advice.

I had this issue! I was 227 & I'm 5'5. I had two doctors completely shut me down when I called to inquire. The first doctor I started w/ actually wrote other things in as comorbidities like my depression & anxiety (all my tests were normal). They were almost certain I would get approved. When COVID hit, I gained like 15lbs so I ended up hitting that 40BMI mark. But yes I think depending on your insurance they may consider other things minor comorbidities. I dropped weight before surgery and went in at 227, all was good! Hope everything goes well for you, don't let anything discourage you!

Share this post


Link to post
Share on other sites

sleep study is your best bet at this point. Are you snoring or/and waking up with head aches or waking up tired and non refreshed? Or do you sometimes wake up feeling like you are short of breath?

Share this post


Link to post
Share on other sites

Thanks everyone! I did the sleep study at home last night. God knows if I did it right, that was interesting! Going to see how that goes first. Let’s see what happens!

Share this post


Link to post
Share on other sites

Allienyc, this sounds very familiar, as I am in a similar position. When I started this process, I was 284, with a BMI of 41.9. But, after meeting with the doctor and the psychologist and dietitian, I started following their advice and have been working on getting healthier habits and losing some of the weight. The problem is that I was too good at it- in 30 days, I dropped from 284 to 258, putting my BMI at 38.1. My insurance was "approved", but my nurse navigator said that my weight could cause them to decide not to pay at the last minute.

I have high blood pressure, but it is well controlled with medication. I also have high cholesterol, but it is also well controlled with medication. I have been using a CPAP for years, but haven't had a sleep study in the last 10 years, so it isn't in my records.

I have an appointment with the sleep specialist this week and we're hoping to get a sleep study done before my surgery on the 21st so that we'll have the documentation we need to have the insurance approval. This all seems so unnecessary since one of the things I'm hoping for is to be able to get rid of the CPAP once I lose the weight.

Share this post


Link to post
Share on other sites

On 8/25/2020 at 1:59 PM, Allienyc said:

I live in the NYC area but am looking to have the surgery near Nassau county, Long Island. My insurance is Emblem Health/HIP for employees of the City of NY.

Have you checked out the bariatric program at NY Presbyterian @ Columbia University? I was cleared for surgery with a 35bmi and a few comorbidities. High cholesterol was counted for me. So was joint pain with the beginnings of osteoarthritis.

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

  • Recent Topics

  • Most popular:

  • Together, we have lost...
      lbs
    ×