Insurance issues

So my doctor's office applied for a pre-authorization to get the ball rolling for gastric bypass. My insurance denied it. I have Sanford health North Dakota PERS. We appealed and they denied me again. They are saying I haven't been big enough long enough (a year). Now, I have weighed about this much before (about 2 years ago) however, lost weight and have gained it back. They don't count those times. You have to be over 35 BMI with an underline issue for a year OR over 40 for a year with no other issues. Now I have issues (oh boy do i lol). Mainly it's my back. I just thought I would ask what other people have done to help get approved. I'm struggling with getting denied.

so sorry to hear about your struggles.

back pain is not considered a comorbidity that will qualify you if you have a lower bum.

gerd,sleep apnea are some that will qualify you. Hope you get it worked out

Man, I've been really struggling with getting denied. I feel like me losing weight is being used against me sometimes. I try so that means the year has to start all over. I have my annual physical in November that will include a bunch of blood tests. The last time I was this heavy my blood tests didn't come back very good. The first time it's recorded I was above the 40 BMI was in May. That means I would have to stay just above that 40 until next May. I struggle because I've tried so many things as far as loosing weight and I just gain it all back. So do I try and lose weight again and see how it goes. Or do I stay just above the 40 for another 9 months to get approved.

Have you been tested for sleep apnea? A large percentage of people that are obese have sleep apnea issues even if you don't realize it.

I'd push for a sleep test.

Sorry. It does suck that they are holding you losing weight 'against' you. Some insurance companies have the strangest requirements.

I would also so for a sleep apnea test. Do you snore? I would also not lose over the next year,making sure my BMW got to 40 or over. It would not have been hard for me. That is what I would do if I couldn't arrive at a legit cormorbidity.

I tried to have insurance cover my surgery (VSG). After several tests and studies, I simply did not have any co-morbidities. It was a very distressing and depressing time because I found myself wishing I was sick. I wasn't (yet), but I sincerely felt it was just a matter of time. I had to have my surgery self pay, which was difficult because I'm a single mom. But it was/is worth it. If you are unable to find a way for your insurance to pay, it doesn't automatically mean you cannot have the surgery.

It's bad that the ins is including the times that you weren't obese. In fact it seems weird that they'd start the clock over again if ever for 1 minute that you didn't meet their weight criteria. Is that a new policy or something else they're assuming so that they can deny you wls?

I would probably want to see in writing what they consider as continuous you being at a certain bmi. Is it a year or 2 of no change? When do they consider it a change & for how long, a day? a week? a month? When do they start over with a new weight? Plus I would want to know what they have documented as you being a different weight, was it what you remembered off the top of your head?, or something the Dr submitted.

I would get a list of the co morbidities that the ins says you have to have & get tested for them so that you could get wls at a lower bmi. Get your policy in writing.

How much do you weigh now?

about 270ish I'm 5'6