WLS with a BMI of 35-40?

Hi!  I'm still rather new to this site and have never posted before.  I've been researching WLS and know that with a BMI under 40 you need to have other health concerns such as hypertension, high cholesterol, etc.  to quaify for surgery.  I'm thinking of pursuing having lap-band surgery done, although I am open to suggestions.  My BMI is somewhere around 36-37, definitely not below 35 (depends on just how much and what I've been eating for a couple days prior to weighing myself).  My question is, can anyone tell me just how hard it is liable to be to get the Drs and/or insurance (Harvard Pilgrim) take me seriously?  Are they apt to try to put me off because my BMI is in the low end of what is considered a qualifying number?  

hi! i'm certainly no expert here about medical insurance stuff. but i wold call your carrier and ask what the guidlines are and what is covered....... bottom line. find out the name of the person you talked to and write it down with the date that you spoke to some one...... then call back and ask the same questions again. you will get someone else  probably to talk to, and write down their name and date spoekn too......... i got this advice from the shrink very early on......... that way you know what is exactly covered, and your eharing it from 2 different people from the insurance... and if they have conficting information, then you really need to ask alot more questions to get verification as to what is what....... every insurance company has different qualifying requirements

I think at this point----MOST insurance companies have a very definitive plan on what they will and will not cover and HOW to get there.  For instance cigna has BMI guidelines, but also a ton of other hoops to jump through. Do you have other co-morbidities?

My BMI is 36 and I either have or are at boarderline for having metabolic syndrome.  I've never been treated with medication, but have had mild hypertention and high cholesterol and triglycerides, as well as the classic "central adiposity " with a waist circumference greater than whatever their criteria is for women (can't remember exactly what it is, but I recently checked it out and it fit the criteria).  I've managed to bring down the choleterol and HTN with diet and exercize, and then of course they go up again after I gain the weight back.  All of this sets me up as heading for type 2 diabetes if I don't get my weight under control.... but I know that potential won't sway the insurance companies.  Actually, Harvard Pilgrim sounds like they might be okay to deal with, but my employer changes insurance companies the first of July, and heaven only know what they will come up with.  I've contacted my PCP for getting labs (to confirm just where my cholesterol is at as well as checking my TSH because I'm on synthroid secondary to having a thyroidectomy) and a physical done and plan on having all my arguments in place to request his referral.  Of course, he can't see me until sometime in June, so it just complicates matters as to what insuranc I will be dealing with.  I'm thinking I should probably just figure out how to finance it on my own on the likely assumption that whatever insurance I have by the time all the requirements are in place will probaby reject it. 

Thanks for the more information.  Of course, all surgeons are different---mine REQUIRES a 'letter of medical necessity' from your primary care physician.  In other words, he wants your primary on board with the belief that this is what you need. The other thing you will need documented is what you have done over the years of weight loss attempts.  You have had to try many....  My insurance also requires six months consecutive visits with your primary or a 'supervised' weight loss program. If you are having your labs drawn---have the doctor draw a fasting insulin SERUM level.  This is DIFFERENT from a fasting GLUCOSE.  A fasting glucose measures the amount of sugar in your blood.  A fasting insulin serum measures the amount of insulin.  If the insulin level is higher than normal---you are insulin resistant.  MOST doctors only check the glucose levels and then say, 'oh there is no problem'.  However---you can have elevated insulin levels for YEARS prior to any glucose elevation. With the insurance--that can be tricky since they will be trading over.  All your labs and stuff will certainly carry over---many docs also require a gall bladder ultrasound.   I am sure you can read up on self-payment.  I just will throw this out as a cautionary measure.  If you are one of the unlucky ones that ends up with a leak---and are in the hospital for four weeks or have other complications related to the surgery....your insurance will cover NONE of that as it comes from a non-covered proceedure.  It can destroy you financially if anything were to go wrong...just something I learned when looking into financing myself. Good luck, it is not an easy road. Michelle

Oh yikes! I hadn't thought about the possibility of not being covered by insurance if something went wrong during surgery.  Good thought about the fasting insulin serum level, my PCP would be likely to just draw the fasting glocose.  As for potential surgery, Harvard Pilgrim requires WLS be done at a qualified "Center Of Excellence."  CMC is the nearest one for me, and couldn't be more convenient for me.  Of course, the insurance may be different by the time I get to that point.  I have met Connie Campbell (not related to WLS) and like the idea of her being my surgeon.  I have the info session coming up next week.  The first one I signed up for in March was cancelled.  Anyway, thanks for the input.  You're right, it definitely isn't an easy road, but hopefully I'll learn something on the journey.   Do you mind if I add you to my friends list?   ~Donna 

Hi,       Don't know how close you are to having surgery but..... I had Harvard Pilgrim and they where awesome.I have an underactive thyriod, high choleterol, and am pre diabetic (diagnoised a month before they okayed my surgery) with a  BMI of 36. I had my surgery in Oct.  ANy other questions I can help you with let me know.

I haven't gotten my referral from my PCP yet, and before you sent your post was feeling pretty discouraged about my chances of being approved.   I DO have Harvard Pilgrim, but that may change on July 1st (not sure what my employer is going to dowith that yet).  Which surgery did you have?  Do you mind telling me if you had been on medication for the high cholesterol?  I got the impression that  insurance companies preferred that medicatons have been tried.  I have no thyroid, was removed seven years ago.   I'm pretty sure I meet the criteria for metabolic syndrome but will have my doc confirm that when I see him.  My BMI is 36, down from around 40 seven years ago.   My daughter is expecting a baby down in Virginia in June, so between going down there to help when the baby is born and the insurance being in question, I'm kind of in limbo right now.  I do thank you for your input.   

Hi Donna              I had my lap band "installed" ,LOL, in Oct. I really worried about my ins the whole time. I was not on a cholestrol med at the time although my cholestrol was 285. I had reactions to the statins. I am on Crestor as of two months ago. I have been on thyriod meds for 30 yrs. My endo adjusted my thyroid meds 4 yrs ago, cut it in half after all the yrs of taking the same dose. My cholestrol went from 180 to 285, I developed high blood pressure and in the last yr pre diabetes. I also had Reflux but again was not diagnosed till after I was approved for surgery.   The only problem I had with Harvard Pilgrim was...they would not talk to me ! I pay them but they won't talk to me only my doc!   Which surgery are you having?? Are you using Portsmouth?? They are greart. I live in Atkinson but it was worth the travel when I had to. Sime things I had done in Derry.                                                                        Linda PS I alsio documented in my application all the diets I had suffered through over the yrs.  If I can help along the way let me know.

Hi, I am sched for Lap-band surgery next month (by Dr.Campbell)- and my BMI is approx 37 - I am pre-diabetic with mild hypertention and elevated cholesterol, none of which I take medication for. I also have Harvard Pilgrim they approved my surgery without any issues. But I went through a series of behavior mod, psych eval and nutrition councelling all through the Obesity Treatment Center in Manchester. OTC, Dr. Campbell & CMC are associates and the 3 groups work together to help you find the best "fit" for you.  Changing ins comp this summer is a real bummer, hopefully the new company will be open to WLS. HP has a reputation of being easier to get approval. As for getting a referral from your PCP, you sound like he/ she might not want to give it to you. But you need to understand that its not up to him, if you want it, tell him to give it to you. Even if he is not open to the idea of WLS, he still is working for you (you pay him) so get your money's worth! LOL Good luck Linda