Denied by insurance

[Ksho 0]

Has anyone been denied because your BMI was not 40, 1 year prior? My BMI is 46 now with two co morbidity that I am getting treatment for but BCBS federal is denying me because a year ago it was only 38.6 and I was only pre diabetic. Just wanting to know if anyone else experienced this!

[Happymouse13 17]

Did you ever get an answer to this? My BMI is 40 now, but 2 years ago it was 31. I'm nervous that I will get denied too!

[kerrik54304 33]

I have never heard of anything like this. That is insane. I have just been approved and my BMI is around 39. I had my Lapband removed 3 years ago and my BMI was around 32 and I have steadily gained weight since then.

[nursesunshine 9]

BMI and comorbidity needs to be present for at least 12 months if you are seeking eligibility based on BMI of 35-39.9 with at least 1 comorbidity.

If going by BMI of 40+, you need to have that BMI for at least 12 months.

Turned out the month my BMI hit 35 was also the month (07/2020) I was diagnosed with mild OSA and started CPAP therapy.

My consult was in February, I had planned to pay out of pocket. My insurance coordinator recommended I wait until July to submit my paper work. Paper work was submitted 07/07, approved 07/13 and I had surgery on 08/04.

Edited September 15, 2021 by nursesunshine
Incorrect date

[Happymouse13 17]

Nursesunshine: Is that for all insurances? The 12 + months?

[kerrik54304 33]

It was not the criteria for my insurance.

[nursesunshine 9]

5 hours ago, HAPPYTRACE said:

Nursesunshine: Is that for all insurances? The 12 + months?

No, I only know about FEP BCBS.

[Gigiwilliams 0]

With FEP BCBS dis you have to submit proof of other weight loss programs that you have tried in the past and did not work?

[Watchjulshrink 6]

On 10/12/2021 at 00:13, Gigiwilliams said:

With FEP BCBS dis you have to submit proof of other weight loss programs that you have tried in the past and did not work?

Wondering if you ever got an answer to this? My doctors office called me today that my FEP BCBS is denying me because I submitted records of payment for WW and other programs but not something from a doctor showing that I had medical consultation for a year prior and that didn’t work. Feeling very frustrated and defeated right now. Thanks!

[kerrik54304 33]

I think most insurance companies want you to go through a doctor approved weight loss program. I had to meet with a dietician every month for 6 months.

[Watchjulshrink 6]

On 08/03/2022 at 21:07, kerrik54304 said:

I think most insurance companies want you to go through a doctor approved weight loss program. I had to meet with a dietician every month for 6 months.

Yeah I completed the 3 months of nutrition counseling with the surgeons office, but now they’re requesting a year of documentation that I did work with my PCP on my weight loss. Provided them 10 years of receipts from WW, weight logs from yearly exams, etc to show the weight didn’t magically appear in the last week (apparently that can happen with a BMI over 40 😂😂) SMH lol

[kerrik54304 33]

Sigh. So many hoops they make you jump through. I’m sorry they are doing this to you.

[ReadyToEvolve 1]

Following this thread. I wonder if the different states have slightly different requirements regardless of federal plan, because subbed out to the different areas. So far I see in WA it’s with either Primera or regence and their requirements differ slightly even amongst them here and what I was provided via FEP was the same as the local requirements. I read up on a few other states and there are additional differences. Have my first visit next week so hoping to clear up some additional questions. I had doc appointments but wasn’t weighed there and guessed my weight at the time (facepalm) this was before I knew/wanted the surgery. Also I think my height has changed and I’ve been using what I thought I was forever and that would also alter BMI. Hoping I don’t have to wait even longer….

[lussa 21]

I have BCBS Fed and I didn’t have any specific evidence of previous medically supervised weight loss interventions so I freaked out about that, but I managed to get approved. I did go over my history with my dietitian and there’s some indication of weight loss in previous claims so maybe that’s what counted.

[St77 85]

I have BCBS FEP and aside from working with a previous nutritionist for nearly a year without success of meaningful weight loss, I only had to attest to trying to lose weight other ways.

I was worried they wouldn't approve me, but it went through without issue.