what is considered medically necessary?

Kay1a
on 7/4/13 7:52 pm
Hello everyone
Im new here and im looking to get gastric bypass. Ive gone to some information sessions at Beth Israel deaconess medical center. Ive also completed some mandatory appointments such as: blood test, abdominal/gallbladder ultrasound, sleep study, nutritionist and psychological visit. Next week I have my last set of appointments which consists of an EKG, meeting the nurse and last but not least the medical director.

Im beginning to get nervous about whether or not ill be approved. I don't have any Comorbidities like high blood pressure or diabetes, if anything I have an arthritic ankle. Im still waiting on my sleep study results to know if I have sleep apnea or not. I guess what im getting at is this: is having a high BMI considered medically necessary? I have a BMI of 51.3 and have network health forward for insurance. Ive called them and from what I gather my surgery has to be medically necessary to be approved.

Any thoughts or answers to my questions and concerns would be most appreciated. Thank you
noftessa0401
on 7/9/13 6:50 am - San Diego, CA
RNY on 12/27/12

They don't seem to give a lot of info, do they?  (I just did a quick google search).

You need prior authorization, and it seems to be based on whatever they deem medically necessary.  I would think that a high BMI, such as yours, would qualify.  In fact, some of insurance companies forego the 6-month medically supervised diet if the BMI is higher than 50.

Good luck!

HW: 274 | SW: 232 | CW: 137 | Goal: 145 (ticker includes a 42 pound loss pre-op) | Height: 5'4"

M1: -24 (205) | M2: -14 (191) | M3: -11 (180) | M4: -7 (173) | M5: -7 (166) | M6: -8 (158) | M7: -11 (147) | M8: -2 (145) | M9: -3 (142) | M10: -2 (140) | M11: -4 (136) | M12: -2 (134) | M13: -0 (134) | M14: -3 (131) | M15: +4 (135) | M16: +2 (137)

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