Question for all??

Did everyone have a BMI of at least 35 (with co-morb) or BMI of 40 for the last 4 out of 5 years before surgery?  It seems this is a requirement from BSBC State Employees.  I have been overweight for the last 5 years, but have had a BMI of 35 (with co-morb) for only 1/1/2 - 2 yrs (now it's 39).  As soon as I started getting overweight, I started with the complications - HBP, high cholesterol, acid reflux, etc.  In January of this year I was diagnosed with type 2 diabetes - reading was 689.  I was in the hospital for 5 days and am now on 2 shots and a pill daily.  There's a big family history of diabetes and I'm scared to death.
My insurance has denied me and so far my doctor's office hasn't done anything.  If I have to be like this for another 2-3 years, I'm afraid I won't make it.  I'm only 50 yrs old and spend $200 per month on medications.
What is wrong with this system? 

I'm not sure what the requirements are for your insurer. It would be best if you can calll them and ask. Also see about posting this question to the Insurance and Main forums, maybe the RNY forum as well. You may cast a big enough net that you can get an answer from someone else who as direct experience with the situation and insurer.

Wishing you all the best,

Barb

Hi!

I'm a state employee and was approved for lapband.  I had surgery in June.  I didn't have five consecutive years of weight history.  They were even going to use an ER visit from when I was 12 if we hadn't found something more recent.  So if you were ever overweight prior to the last five years, you may be able to use those weights.  Oh, and you can use this year's weight as one of your five.  I did have a BMI over 35 for all the weights I submitted.  I would appeal and make sure to include all your co-morbidities and how severe they are and what the treatment consist of (including meds) and costs (to them).  They may see that covering the costs of these will be more expensive to them than the surgery.  Unfortunately, the bottom line matters a lot to insurance companies.  Good luck!

--Amanda

The State Health Plan denied you?  With those types of stats?!  That's unusual.  I had only "sketchy" medical records due to the fact that I rarely went to the doctor. I think I had 2001,2004,2005,2006,2007.   I was diagnosed with my two comorbs. (HBP and Diabetes) in January 2007.  I was referred to the WL surgeon in October in 2007 and had surgery in March of 2008.  Who's your doctor?  I've heard that if you go to a Bariatic Center of Excellence things go pretty easy for BSBSNC members.  My doc was at a BCOE and things were hassell free. 

Good luck to you!

Thanks for the replies.  I applied at UNC Hospital.  Dr. Tim Farrell is the surgeon ( I have yet to meet him.)  I've already been through the psyc eval and met with the dietician.  They both recommended surgery for me.  I met with one of the other surgeons and he also recommended the surgery, along with my PCP.  UNC is not a Center of Excellence, but it is a major medical center.  I guess I'm going to have to appeal this myself.   

If you are willing to change programs and BCBS can tell you who their COE's are, it might help. It depends on if you want specifically want their program. I think that they have a good one, but I didn't use them because my insurance required a COE  and they aren't recognized by the ASBS as a COE yet mostly because they don't do enough volume.

All the best,

Barb

If your insurance continues to deny you please try your local Vocational Rehibilitation Center. I was denied 3 times by my insurance and went thru my Voc Rehab and they are paying for my surgery. good luck

Thanks, ya'll.  I am considering going elsewhere.  A friend of mine went to Dr. MacDonald and highly recommends him.  In fact, he is closer to me than Chapel Hill.  For some reason my PCP did not recommend Greenville.  I'm think I'm going to make an appointment soon.

I went to Dr MacDonald yesterday for my 1 month visit.  I have lost 38 lbs and I am doing great.  At Southern Surgical, they have a support group meeting the first Wednesday in the month at 7:00 p.m.  My cousin and I go each month and if you would like to go with us, please call me and you can ride with us.

Rachel

PS DON'T GIVE UP, I REALLY FEEL LIKE GREENVILLE CAN HELP!!!!!!!

Thanks, Rachel.  I just might take you up on that.
The nurse at UNC finally called me this morning.  She wants me to appeal the decision.