Advice about insurance/approval process please!

Hi everyone! This is my first post here. I am just starting the whole process of doing the requirements to get approval. I've done tons of research and decided I absolutely want the DS because from what I have read it has the best weight loss, best long term results, and least restrictive diet after. My doctor agrees I am good candidate for DS. Now here is my problem: I have Cigna insurance. My coverage is actually very very good, but for some reason their requirements for DS are stricter than any other surgery they cover. They require a BMI over 50 for the DS. I do technically qualify at 5 feet tall and 260 lbs, but just barely (BMI of 50.8). If I lost even 5 pounds during my required 3 months supervised diet, I will no longer qualify. Its pretty sad that because of this insurance stipulation, I have to worry about making sure the diet program DOESNT work at all. I also haven't found any other sources that say a BMI of 50 is necessary for DS. I guess its just Cigna's way of getting out of paying for the more complicated/expensive surgery by imposing a higher reguirement.

Anyway, does anyone have any advice for me in this situation? I'm also curious if anyone has had their surgery at AtlantiCare in NJ? I am working with Dr Onopchenko.

Also, anyone else out there with Cigna? I have an Open Access Plus plan. If you have Cigna, how long did your approval take? How was your experience with them?

If my BMI were to fall slightly below the 50, would I have any luck in appealing? My Dr. doesn't approve of doing a bypass on patients who are former smokers because of the high marginal ulcer risk, and I am a former smoker, so if they deny my DS, I won't even be eligible for my 2nd choice....ugh this is frustrating. Anyway, thanks in advance for any advice! :)

Many count your "starting weight" as what they submit, so your present weight would be that weight.  If you went to a seminar and they recorded your weight, that should be what they use.  You can call your insurance and ask them to be sure you're doing this right.

Thank you, thats great to hear! I hope thats the case. Yes my weight was recorded as the 260. Thinking back, maybe I should have worn ankle weights or something for the initial weigh in to give me a little more wiggle room, haha. It is so insane that for the first time in my life I am worried that I don't weight ENOUGH. I am super morbidly obese with sleep apnea, hypertriglyceridemia, hardly get my period anymore, and I have some trouble with basic daily activities.

Another question I have is: Can the results of the 3 months supervised program have an effect on approval? For instance if someone stays the same or even gains a couple pounds, will they be denied because they say that shows they won't be able to be compliant with post surgery guidelines and all? Or, if the program actually works and you lost some weight, can they turn around and say "well you lost some weight with the program, you don't need surgery"?

Sorry for all the questions! I just want to make sure I do everything exactly right. I will lose my current insurance on my birthday in August. I'll still have insurance as I will have a new plan starting right away but it won't be nearly as good as far as out of pocket expenses. Is it feasible to expect to get in for surgery before my birthday? Cigna only requires the 3 months so I will have the requirements completed at least 3-4 months before my birthday.

I don't want to live like this anymore. Actually I CAN'T. I'm 25 years old and feel so much older. I have a 2 year old nephew who I adore and I hate that I can't keep up with him like I should be able to. I'm in nursing school which I love, it has been my dream to be a nurse forever. But I know if I don't lose this weight and improve my health I will never be able to handle the physical requirements of being a nurse.

Thanks in advance for any insights :) This board is so great, I am so glad I found it!

Make very, very sure than your bmi over 50 weight is documented in your medical records. Your insurer should not deny you the DS just because you lose a couple lbs if the bmi over 50 at the start is documented (though of course I can't issue you any guarantee).

My understanding also is that it should not matter whether or not you actually lose any weight during the months of required medically supervised diet. There are some insurers, and some surgeons, *****quire a specific amount of weight loss, but unless that is a specific requirement that is stated explicitly in your EOC (Evidence of Coverage), it shouldn't be required.

So, get your hands on your EOC. Read the exact requirements for yourself. Don't trust some poor soul who answers questions over the phone to get the details right. No one cares about this more than you, right?

Larra

I checked the coverage policy as suggested and you are right - I didn't see anything about having to lose weight during the pre-surgery program. Thank you!!

you are actually not super morbidly obese. You are obese. SMO would be someone in the 400-500+ range. 

Most insurance companies use your starting weight. Do you have any comorbidities,diabetes,sleep apnea,reflux,etc? That will make a difference too. 

If I needed to not go below a certain weight,I would make sure I ate enough to stay at that weight,personally. Wouldn't be a problem for me at all! :)

I had read that the different levels of obesity are based on BMI and that 50+ is super. Maybe that was incorrect, Sorry.

I have sleep apnea and hypertriglyceridemia.  My doctor told me at my last appointment that my levels are not quite high enough for diabetes but "pre-diabetes". I don't know if that is considered an "official" comorbidity or not.

Since I am so close to the minimum I was just worried that not losing any weight at all might make my insurance company deny me. But on another member's advice I read the full coverage policy for Cigna and it didn't say anything about having to lose any weight, just participate in the program.

Thanks for the response :)

You are correct. Every classification system I have ever seen lists a BMI of 50 or above as "super morbidly obese".

Be sure to verify what weight was recorded. You don't want to wait 3 months & have them try to use a random weight. 

I have Cigna, although a different policy. Once my paperwork was submitted, it took them a couple weeks to approve my surgery.

My BMI was also right on the edge for the DS. My doctor told me not to worry about losing during the supervised diet, the use your first recorded weight.