Horizon BCBS NJ Says NO / BMI TOO HIGH????

Got denied today from horizon bcbs nj, they said my bmi is too high. it's 70. they said surgery on someone my size is considered "Experimental" WTF. Dont i need this surgery MORE than someone with a less bmi? Has anyone had this happen to them also. What do i do next. HELP?

Sorry to hear about your insurance problem.  That is screwed up.  If you have a surgeon willing to do the surgery, who are they to say no?  They aren't doctors.   I hope you plan to appeal and not give up.  That's what they want us to do, but we have to keep on fighting.

I can totally relate.   My BMI was 65 and they denied me for lapband.   However they would pay for RNY but because of my lung diease my surgeon said I was not a good candidate for RNY.  So I was devestated.  But I did not give up .    I got my PCP, Lung Specialist and Surgeon to write a letter stating because of my many problems I was not able to RNY and needed the lapband.  If you need more information you can PM me and I will give you more details on how to do this if you want. 

Thanks Folks. No i'm not giving up. They need to know i'm not going away! Got some info today on how to approach this. There is a local Politician who is currently fighting to correct this. I'll be contacting his office and Human resources at my job pushed to have surgery for a fellow worker. They got it thru. So we'll see. Thanks for your help. Wishing everyone on this website the best of Health and Happiness for the upcoming holidays. Be Well -Mike-

Hi Paul, It's the bypass that i'm seeking. Not the lapband. They said anything above a 60 BMI is considered "Experimental and Investigative" They say the gastric bypass my not work for me. Even my surgeon said this is BS.     -Mike-

Hi Mike!  I know the DS has been shown to be the extremely effective for people with a very high BMI.  Have you considered the DS? If not, you might want to go to the DS forum and read some info over there. It's a good place to start your research.  If it's something you're interested in doing, there are tons of "insurance warriors" on that board who love to give information regarding denials due to surgeries being classified as "experimental". Here's some of the latest research that was posted on that forum:

Maintenance of weight loss in patients with body mass index >60 kg/m(2): importance of length of small bowel bypassed.

Hamoui N, Anthone GJ, Kaufman HS, Crookes PF.

Department of Surgery, University of Southern California, Keck School of Medicine, Los Angeles, California.

BACKGROUND: It is commonly believed that weight loss after biliopancreatic diversion/duodenal switch is inversely related to the length of the alimentary limb and the common channel. However, the effect of the biliopancreatic limb length (BPL) on weight loss has received little attention. METHODS: A total of 1001 patients after biliopancreatic diversion/duodenal switch (209 men and 792 women, mean age 42 +/- 10 yr, mean body mass index [BMI] 52 +/- 9 kg/m(2)) were divided into 2 groups according to the ratio of the BPL to the total small bowel length (SBL): a BPL 45% of the SBL. The nutritional parameters and percentage of excess weight loss were compared between the 2 groups. RESULTS: In patients with a BMI of 45% of the SBL (P = NS). At 2 years, the corresponding percentages were 73.7% and 79.5% (P = NS) and, at 3 years, were 73.4% and 75.2% (P = NS). In patients with a BMI >60 kg/m(2), the corresponding percentages of excess weight loss was 56.8% versus 61.4% (P = .07) at 1 year, 62.2% versus 77.5% (P = .04) at 2 years, and 59.8% versus 77.5% at 3 years (P = .05). CONCLUSION: The results of our study have shown that amount of weight lost after biliopancreatic diversion/duodenal switch is directly related to the proportion of small bowel bypassed in patients with a BMI >60 kg/m(2). Also, the effect increased with the duration of follow-up. In less heavy patients, the BPL/SBL ratio had a minimal effect on long-term weight loss and a more pronounced effect on nutritional parameters.

Unclefluffy - I read an email from my PCP tonight - I'm not big enough - BMI 37.5 but have comorbids diabetes, BP, cholesterol... I was past pissed.  I sent her back an email saying I could up my BMI w/o really trying. I have Kaiser they only do the RNY or LapBand, neither of those will cure my diabetes but the DS will.  So I have an uphill battle starting out too. Don't give up your fight.  I should have contacted her weeks ago, I let it go for almost 6 weeks after she made the referral.  Too many give up because of the hoops insurance companies make us jump through.  I'm taking this all the way to CA Managed Health Care - they've been overturning HMO's who are denying the DS as experimental because their surgeons don't do it.  At least the DS will leave my stomach overall intake/outtake in place and just remove the greater curvature so that it's restrictive then the switch with the intestines for the malabsorption - no more diabetes...I couldn't be more ready. Good luck on your fight. Chris

Hi there I don't know much about insurance as I self paid for my surgery (written exclusion - set in stone) but I wanted to chime in and say before you really start fighting the insurance co do plenty of research first on your choice of surgery. The DS sounds as though it could be a possible alternative for you.  It is proven the most effective at long term weight loss and patients typically lose 80-95% of their excess weight.  This figure compares to a typical excess weight loss of around 60% with the RNY. The DS can also be done in two parts with high risk patients, the stomach part of the procedure is performed first which produces a banana shaped fully functioning stomach, it removes the part of the stomach which produces gherlin, the "hunger" hormone so you get restriction plus a reduced appetite.  When a certain amount of weight has been lost the full surgery is then finished with the intestines rerouted which results in the long term weight control as the patient then malabsorbs a proportion of everything he eats.  The stomach portion of the procedure is the vertical sleeve gastrectomy then the intestinal part deals with the weight maintenance long term.  With the VSG after a patient has lost a significant amount of weight and therefore is less at risk from surgery the rest of the procedure can be added on.  The whole thing can also be performed laproscopically which again may reduce the risk, it would certainly make recovery easier.  In short you will lead a "normal" life and eat normal food in normal portions but your body will no longer be able to absorb it the way it does now.   The downside?  Regular blood work to keep a check on vitamin and mineral levels and daily supplementation of essential vitamins and calcium.  You will however have to supplement with other surgeries.  Not every surgery is suited to every individual but the DS may be an option you haven't heard about before so I thought I would let you know so that you can research some more. At the top of this page under "forums" you will find a listing for the DS.  If you would like to find out more please come on over we would be happy to talk and there are some expert insurance fiends there! Good luck to you in your search.    

5'7"   SW 268lbs BMI 42/ CW 132lbs BMI 20.7 / GW 140lbs
136lbs  Lost 

                            I Ymy duodenal switch