Ins and co-morbids...

mrlddst · May 16, 2005

I have always considered myself a fat healthy person (is that an oxymoron??) I don't have any existing health conditions other than being fat, well let me clarify. I'm 5'1 and weigh 240(give or take a few). I don't have diabetes or high cholesterol. Although, since I started reading up on WLS I have developed back pain and have trouble standing up for a long time, my feet and knees start to hurt. Should I go see a doctor about this? I have a high tolerance for pain so I normally would just take 2 advil and suck it up, but I think these may support my insurance approval. I am also getting tested for sleep apnea. Are there anything else I can do? I saw something about attending nutritional classes, but have no idea where to find those in my area.

the best me · May 16, 2005

I think, and someone correct me when I'm wrong, that you should start with a visit to your PCP and get your weight related complaints documented. At some point, you will need to ask you PCP for a letter recommending WLS, and the Band in particular. so that conversation needs to happen.

When I was looking into my local band doc (before i found out my ins didn't pay and ended up in MX for the surgery) they have PCP's nearby that know how to document, submit letters and file properly, so perhaps you could change PCP's and find an in-network linked to the WLS surgeon you plan to see?

Good job on the sleep apnea test. If you have it, you need to know, and that is a definate co-morbidity. One down, one to go, unless your BMI is higher than 40. At 5'1" it might be! Check on that one, too (your BMI).

Good luck! I hope this has helped, but stay here for other, more informative posts. Someone else my dissagree with me or have better advice....

mrlddst · May 16, 2005

Thanks, I checked my BMI its at 43. For some reason, I don't think that I will get approved (like my ins company is just going to say no without even trying). I'm one of those people that prepare for the worst, and "try" to hope for the best (guess I'm just a pessimist). I just hope that I can cover all my bases. I don't know what I will do if I get denied. I am considering self-pay but I don't think I can afford the fills after paying for the surgery.

the best me · May 16, 2005

I went to Blue Cross online and enrolled, then looked up my plan number and did a search on weight loss surgery and found out that Lap Band is specifically excluded. Perhaps I could have fought it and won, but instead I just bucked up and paid cash in MX and I'm glad I did. It would have taken years, I assumed, and I didn't feel like I had years to wait. This way, it's done. But check with your specific plan and see what it says is covered or not. That could tell you which direction to head at this point. With a 43 BMI and possible sleep apnea, you have a fighting chance. Besides, you don't need 2 comorbidities with a BMI over 40.

Boy's Mom · May 16, 2005

I too have Blue Cross. My plan booklet said specifically that anything related to weight loss was excluded. However, because of my high BMI (49), diabetes, joint problems and just diagnosed sleep apnea I was approved based on "medical necessity". So don't give up too easily. I was approved within 2 weeks of submission by my MD. My first visit to the surgeon was 11/16, and I had surgery on 2/28!! I am truly grateful to everyone along the way.

Mayra

Alexandra · May 16, 2005

With a BMI of more than 40 there is no reason to invent comorbidities if you don't have them. The BMI number alone is enough to establish medical necessity for bariatric surgery. The question is whether your carrier excludes bariatric surgery EVEN WHEN medically necessary. If you can find out that it doesn't, you'll be in great shape for approval.

mrlddst · May 16, 2005

Your right, I am just extra anal when it comes to some things. I want Cigna to approve me without being denied but there is nothing I can do except pray on it. I am afraid that my PCP will not write a letter in my favor. She is one of those doctors that believe I'm not doing enough. Even though I have followed all of her weight recommendations for the last year and a half and I have actually put on weight. And prior to my move to VA(live in NJ for 2 yrs), I was under another doctors phentermine prescribed diet. I did lose 50 lbs but when I stopped due to fear of what was happening to my heart, I gained 70 lbs. I have an appt with her on Friday, but admittedly I'm am scared that she will say no. And if she does, I know I can switch but then who do I see who can recommend me after that.

I have called Cigna at least once every day, just to ask about exclusion and bariatric surgery. They keep telling me about the medically necessary part and when asked about the LB surgery, they said there is no exclusion(of course there is the experimental bit, but I hope they dont try to pull that one on me). I read the benefits guide from 2004 and we have open enrollment this coming June, it looks like the plan changes.

oemastiff · May 29, 2005

I wonder, has anyone been approved for ins without co-morbidities but with BMI above 40? I'm in NY and insurers can't exclude bariatric surgery. I know that bmi above 40 meets NIH standards for WLS, but HAS someone actually gotten an ins co to pay? Is this a stupid question? I hope not!

Barbara

Alexandra · May 29, 2005

Barbara, yes indeed people do get approved without comorbidities if their BMI is over 40. Absolutely, positively, yes. My surgeon's office's insurance experts say to the preops every single month that if your BMI is 40 or above you qualify medically, period.

Whether your insurer will pay for your band is another question entirely, but if they deny it the reason will NOT be that it's not medically necessary. If your BMI is 40 or above, that's a given.

I'm one of those people who had to fight my insurer, but it wasn't for medical reasons. My BMI was 47 prior to surgery and they approved weight-loss surgery immediately though I was otherwise healthy. It was banding they had a problem with. (I fought it and won, for the record.)

mom2mygirlz920 · May 29, 2005

I guess I am extremely lucky with my ins. I have bcbs of illonois ppo and I was approved in less than 24 hrs. I have a bmi of 39, and bad knees that they have paid for 2 surgeries. They also pay 100%. I didnt realize that was such a big deal!

oemastiff · May 29, 2005

Well, my ins will cover WLS if it's medically necessary, according to our policy and Customer Service. And I know that they have covered the band, so maybe all is not lost. I have the info seminar 6/15.

Barbara

flower · May 29, 2005

I have blue cross blue sheild new england and if you have a bmi above 40 they will pay i was approved bmi 42

okiejudy · June 8, 2005

My ins just denied me. I have a BMI of 36 but I have had surgery on both knees and high collesterol. They said I didn't have enough co-morbidity. I guess you have to be dying. I am so frustrated.