Hi everyone! I've been going through all the posts here, and I can't tell you how helpful you all have been! After a life long struggle with my weight and much research, I've decided to pursue wls. But I'm wondering if anyone has had difficulty getting insurance approval with a BMI of 35; my insurance (BCBS MA PPO) covers if you have a BMI of 35 w/ comorbidities, but what if I lose weight from the time I'm approved until surgery? Anyone run into this from doing their pre-op diet?
I've fluctuated between a 35-40 BMI for the past five years (I can diet...I just have a problem keeping it off) and I'm just over a BMI of 35 now w/ GERD, back pain, and high blood pressure, but I want to go into surgery as healthy as possible, but don't want to risk my doctor or insurance deciding I don't need it anymore.
My family history is fraught with weight problems, both my parents have type II diabetes, high blood pressure, bilateral knee replacements and sleep apnea due to their weight, and all six of my siblings are morbidly obese w/ similar issues. I really want to get this done before I end up with more serious problems like my family has, but I'm not sure if my doctors and insurance company will understand this.
For starters, I'm sure you have tried diet and exercise a hundred times, so moving on...
Check with your insurance as to whether they require only 1 or 2 comorbidities. I believe by most insurance standards, you currently only have one (high blood pressure), so that would be my first question.
The question of what happens if you lose below a BMI of 35 is one I've heard before. I sure wasn't in that position, but my understanding is that they typically go by whatever your weight was when you first consulted with a surgeon for WLS. Once you're approved, you're approved, so don't worry about any weight you may lose between approval and surgery day, as most surgeons require a pre-op liver shrinking diet (typically either a low carb diet or a liquid diet) for anywhere from 2 days to 2 weeks before your surgery.
I would also check to see what the requirements are for your insurance beyond BMI and comorbidities. Many require that you provide a 2-5 year history of being morbidly obese. I had to provide documentation of my weight for the 2 years prior to my surgery. This was not a problem for me since I've been overweight since I was 4, but if your BMI has been below 35 in the past couple of years and they require this documentation, you may have another hurdle.
Also, many insurance companies require that you participate in a medically supervised weight loss program for anywhere from 3 to 12 months before they will approve you for surgery. I had to do a 6-month diet with my PCP before insurance would approve me (that was for BCBS of NJ, but al BCBS plans are different).
Without getting into the 30 or so diet programs I've already tried, and failed at, believe me, I've tried. I would never have thought to turn to this as a first option, this is a last resort. I've done atkins, weight watchers, medifast, diet + gym, curves, spark people, the body bug w/ 24 hour fitness, jazzersize...jesus, you name it, I've tried it. And I always gain it back with a little more. Recently I've been fighting to stay at 225...but I'm slowly inching back up. If I don't do something now, I'll end up at 350 like my mom and sisters, sleeping on a machine, fighting diabetes. I don't want it to get to that. But thanks for your input.
I have read a few posts from folks who had a BMI of 35-40ish with some co-morbidities, who were approved for the lapband. I'm sorry I don't know the details, but I know it has been done! Keep researching and check OH too.
Thanks jillybean,
My insurance only requires one comorbidity, and the preauthorization request doesn't say much about diet history etc. But they do require enrollment in a "multidisciplinary evaluation and care program including behavioral health, nutrition and medical management" so I guess those will be the psych and nutrition counseling.
geeger - those multidisciplinary programs MIGHT be a six month 'adventure' for you. and are we talking about Kaiser Permanente here? i've heard they're strict. but the purpose of these programs is in part to show that you can follow directions and that you are motivated to have the surgery. i guess they're trying to weed out those people who aren't committed enough to follow through.
but as for the BMI of 35 with comorbidities, i think Jilly's right [she usually is!], that what counts is your BMI at entry.
Hi Jiffypop, I've been following your posts for a long time! I don't have Kaiser, it's blue cross blue shield of Massachusetts (even though I live in CA) and it's a PPO elect, so I'm really lucky in that I get to pick my doctors and the program for the most part.
I'm prepared for the months of classes and counseling, but most of the programs I've seen only require a few months of pre-op care. But I think I'm prepared for most of this...and I know it's not the magical quick fix some people think. My mom had the lap band put in, but she didn't follow up, didn't get her fills, and ate around the device. And I'm extremely motivated to not have that happen.
BMI of 35, questions about wls
