Insurance Denial

Good morning everyone...I was wondering how I can get insurance coverage for the DS procedure? I have been denied entry into the program by my insurance company twice. Even though my BMI is 39.9 They say I have to have a BMI of 40 or a comorbidity on their list. I have low back pain, and just recently got diagnosed with GERD. These of course are not on their list. Also once I eventually get into their program, I have to be on a diet and excersise plan that is doctor supervised for one year. How do I get around all this so that I can stop having pain and start living again.

GERD can be a symptom of Sleep Apnea.

Ask your PCP to get you tested.
S~

  I'm sure other vets will be along to comment, but I think you're kind of stuck at this point.  Most plans I've seen actually require a BMI of 45 with no co-morbidities or 40 with at least two.  Also, almost all insurance providers require some kind of documented medically supervised weight loss attempt.  I just mention this to point out that you're not alone and this is really a common set of hurdles to have to cross.

If you're looking for ways to "instantly qualify", there are a couple of things you can try.  A BMI of 39.9 is just a pound or two away from being over 40, so you just missed that line in the sand.  Carrying some extra change or wearing some heavier clothes would add some weight, or you could purposely shrink a little when they take your height - either one would likely get you over the magic threshold of 40.  I would think GERD might qualify as a co-morbidity, but if not, I'd have your doctor order a sleep study to see if you have sleep apnea, which is common in obese folks.  I would also have them check for any indication that your cholesterol or sugar levels might be abnormal.  Either of those could qualify as a co-morbidity.  On the supervised diet end, I don't think you're going to have any luck getting out of it.  If it's the insurance company that's requiring it, then you won't have a choice.  If it's the surgeon/surgery center that is requiring it, you could find another doctor that doesn't require it.  

To give you some perspective on other insurance requirements, my carrier required proof that we were over the BMI guidelines for the last 5 years.  Our BMI had to be 45, or 40 if we had comorbities.  We also had to have a 6 month doctor supervised diet within the last 2 years.  We had to pass a psych eval to show that we knew what we were getting into, that we were prepared for life after surgery, and that we had taken appropriate steps in our lives to try to control our weight on our own.  

I know that you're uncomfortable now and that your weight is getting in the way of your real life.  Unfortunately, I think you're going to have to play the insurance company's games (abide by their rules) if you want this covered.  It won't be a quick journey - many on this board have had to wait for several years to get their DS covered, but if it's really what you want, then it will all be worth it in the end.

Jeremy, while the companies who buy the plans can put limitations in place...it's been my experience that most insurance companies follow MEDICARE guidelines which state: 40 or above...35 or above with comorbid conditions.

I HAD NO problem getting approval at a 35.2 BMI and my main comorbid was diabetes.

As far as documentation...that also varies due to companies buying the health plans.

Liz

I have never heard of this. Virtually every insurance company goes by the NIH guidelines which is a BMI of 40, or a BMI of 35 with two co-morbids.

There are lots of way of getting around insurance requirements. Unfortunately the person with insurance expertise who has helped hundreds of people get surgery despite insurance hurdles has been banned from this site.

I was just curious on what insurance you have, since you are in California?  Is it DMHC?  If so, there are good tips on DS FACTS.com website.  Here is the link to that article:

http://www.dsfacts.com/Insurance-Says-DS-Investigational.htm l




Keep us updated & tell us how things are going!!!!!
-Jamie

DMHC, the Department of Managed Healthcare, is not an insurance company,  It is the California governmental department that oversees the insurance companies (i.e. managed healthcare) in CA.

Thanks for the help/clairification, Modesto.  I knew there was MORE to it than what I wrote!!!



I appreciate it
-Jamie

 My insurance does not cover any bariatric surgeries. Thus, I was a self pay. I had my first appt with the surgeon and had the DS four weeks later. We used the money that we had saved for the kids' college!  It was well worth it though. A year of waiting before surgery....i don't know if I could have stuck it out. 

One bariatric surgery place that did NOT perform the DS told me that I had to have a bmi of 35 and two comorbids OR a bmi of 40. I was at 39. When I did meet with my DS surgeon, I purposely "shrunk" myself when I had my height measured.  It worked!  My bmi was over 40. Ha!  In the end, with self pay, it didnt matter.

California's independent review program is very DS friendly.  You'll have to go through the appeals process, but you're so close, I can't see them denying you for long.