Sleeve Surgery - BMI 38; Insurance Question

[Allienyc 8]

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.

[FabNFit@40 52]

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

[Lanie992 168]

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.

[tarotcardreader 196]

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

[Lanie992 168]

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.

[Allienyc 8]

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!

[Jeff 77 2]

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).

[danielleleigh90 124]

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!

[Circlesis 59]

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?

[Allienyc 8]

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!

[billho 243]

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.

[drawingdami 34]

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.

[newyorklady20 97]

I am also a city employee (DOE teacher) and am in the process of getting approved. I actually just did my sleep study last night so I’ll see the outcome - I don’t have any other comorbidities. If you google the insurance, it shows a list of qualifying things that you might end up having. It’s beneficial to go through the steps because you never know what will come up in the bloodwork, etc.
I will also say... I’m pretty sure that insurance covers it flat out if your BMI is 40+. I see that you’re already basically at 38, so... maybe if your BMI became 40 by your first weight in, you would be covered... 😉🤷🏼‍♀️

[shanfries 18]

I ran into the same issue with Aetna. My BMI is 37 and I have no comorbidities. I was worried I wouldn't be able to have the surgery. I decided to look into paying for the surgery out of pocket and bypass insurance. Guess what?! No one cares if you have comorbidities if you pay cash. Very few hoops to jump through. I started the process 6 weeks ago and my surgery is in a week. It would have been sooner if not for Covid. Not sure if you are in a position to pay out of pocket.. it may be less than you think. Just wanted to offer another option if insurance turns you down. Don't give up!

Sent from my SM-T500 using BariatricPal mobile app

[Allienyc 8]

Hi everyone! I realize I never updated this post.

I did the in-home sleep study (basically wore a machine to sleep). When I went to follow up with the doctor, he said it was what he would consider negative for sleep apnea. But, on paper, it was borderline; like an extremely mild case of sleep apnea. That was all I needed to hear! I faxed that report to the surgeon, and apparently it was enough for the insurance to approve me ! My surgery is coming up on January 14!!

There were a few obstacles, and I did get discouraged a few times. The coordinator at the surgeon’s office was giving me a hard time about accepting the previous weights from the primary doctor, but I was persistent. I also kept praying that if it was meant to happen, it would - And now it’s happening! If it were not for those first 3 weights, I would have had to wait at least another 3 months. My insurance requires 6 months of a supervised weight loss program.

In summary, my insurance DID approve it at a BMI of 38 and 1 comordbidity.

Don’t give up if you run into challenges with the insurance and things like that. Keep pushing and don’t be discouraged. Good luck to everyone!

Edited December 31, 2020 by Allienyc