Questions about insurance approval and low BMI to qualify.

Hello,

I had RNY a year go but this question is for my mom. She is 61 and has a BMI of 33.5. She is Pre diabetic, has gerd (don't know that VSG would help that) and could possibly have sleep apnea, not confirmed. She has struggled for a very long time trying to get her weight down. She is a lightweight at 183 but 5'2" in height. She works out like crazy and can't lose the belly. That's where she carries it all. She is thinking of asking her doctor about VSG but doesn't think her BMI is high enough.

I'm looking for information about who was approved with these similar cir****tances or self pay information. Also is her age ok for surgery? She's an overall healthy woman besides the weight and Pre diabetes.

Thanks!

Usually insurance requires you to have a comorbidity and BMI of 35 at least. She should check with her insurance to make sure and also get a sleep test to test for sleep apnea. Age wise I have seen other posters her age who are successful. Good luck!

I had my VSG done in Mexico, self-pay, but the facility only required a BMI of 30 for surgery.

I just went to a seminar with a friend who is interested in the surgery and the doctor said that a lot of insurances are now reviewing any who have a BMI or 30 or above with co-morbidities. She may want to check to see if her insurance has changed.  They do change VERY often.  When I started the process to get my VSG surgery last summer, my insurance required 6 months dietary documentation consecutively.  I stopped for a while and when I picked back up in September of this year, they had lowered the requirement to 3 months and I just got approved for surgery.  So even if her insurance won't approve it right now, they could choose soon.  Just keep checking! :-)

It depends on the insurance. I can tell you right now if it is a group policy with Blue Cross Blue Shield of Texas or Illinois, you have to have at least 35 BMI with at least 2 comorbidities. Easiest way to find out is to either call or go to her insurance website and check their medical policies for bariatric surgery

 

BCBSTX (same policy applies to BCBSIL)

Aetna

United Healthcare

 

**Different states may have different guidelines and employers can choose to overrule an insurance companies medical policy. By this I mean they can require your BMI to be higher or allow it to be lower. These are pretty standard. If you look at all 3 they are almost identical. I still highly recommend her calling her insurance to verify.

While many of us have the same insurance carrier, that does not mean we have the same coverage and guidelines. As a former Payroll and Benefits Administrator the company I worked for had many different plans with the same carrier. We had 6000+ employees in 28 states and 3 countries. Each plan had differences. Also, each State's Insurance Commissioner may have different requirements for insurance companies covering their State's residents.

Get the specific codes for the procedure from your doctor and call the insurance company to inquire about coverage.  Also, make a comprehensive list of co-morbidities and all her health concerns. Some things may be considered a co-morbidity in conjunction with other items on the list. She'll need a sleep study to confirm the sleep apnea.

 

Hope this helps.

Most insurance co. need you to be with a BMI of 40 or 35 with comorbidities.  Her best bed might be to self pay.

 

Patty