Does anyone else have a low BMI and got approved through insurance company

Hello I'm considering the VSG but I'm afraid I may not qualify. However, I told myself I would go the process and if I wasn't approved then I would go to Mexico and have the procedure done but I wanted to at least try first. I'm 5'11 and weight 253 pounds my BMI is a 35.3 but I'm not aware of any comorbidites. My husband has complained about my snoring for years but I have never been tested for sleep apnea and during my last annual doctors visit I was told I was "borderline" diabetic and needed to lose weight. Well I've gained a additional 10 pounds since then and have watched my weight climb for the last decade and now it seems I may be too skinny to get the surgery through my insurance unless I'm sick or I gain another 30 pounds. Is there anyone here who is maybe experincing the same thing? Did you get denied? Did you end up self paying? Did you wait and try again later? Please help, I just don't want to wait until I'm diagnoised with high blood pressure or diabetics to get the surgery or wait until I'm 300 pounds. I'm starting to experience issues with my knees and I'm having trobule getting in and out the car due to the excess weight.

I was cash pay (blah!!) so I didn't have to deal with insurance. However, to qualify for VSG at my surgeons office was this:

Over 40 BMI

or Over 35 BMI with health issues. Sleep apnea and diabetes are considered to be qualifying health issues. 

From what we learned in our seminar, if your insurance does cover it I think it follows these same basic guidelines so you should just call your insurance company and see what their policy is.

 

GOOD LUCK! 

My BMI was only 31 and I had high blood pressure which was treated with a prescription.  I did not qualify, so I paid cash for my surgery.  You need to speak with your insurance and see what their requirements are and where you fall within them before you can decide how to proceed.  

 

I am thinking that you should check on those co-morbitities again.  I am betting that if you were borderline diabetic it wouldn't be a stretch for your doctor to say you were diabetic and you actually might already be anyway.  Also although snoring doesn't mean that you have sleep apnea but having sleep apnea does mean you would be snoring.  I would get this tested out.  Surely your insurance will cover the cost of a sleep study especially if your primary care physician orders one for you.  

I found a website that lists some co-morbities that may be useful for insurance coverage for WLS.

 

Obesity Comorbidities

To follow is a list of comorbidities (additional conditions or diseases) related to obesity which may help you in qualifying for weight loss surgery.

• Family history of heart disease
• Family history of stroke
• Family history of diabetes
• Family history of heart attacks
• Hyperinsulinemia
• Diabetes
• High blood pressure
• Coronary-artery disease
• Hypertension
• Migraines or headaches directly related to obesity or cranial hypertension
• Congestive heart failure
• Neoplasia
• Dyslipidemia
• Anemia
• Gallbladder disease
• Osteoarthritis
• Degenerative arthritis
• Degenerative disc
• Degenerative joint disease
• Recommended joint replacement from specialist
• Accelerated degenerative joint disease
• Asthma
• Repeated pneumonia
• Repeated pleurisy
• Repeated bronchitis
• Lung restriction
• Gastroesophageal reflex (GERD)
• Excess facial & body Hair (Hirsutism)
• Rashes
• Chronic skin infections
• Excess sweating
• Frequent yeast infections
• Urinary stress incontinence
• Menstrual irregularity
• Hormonal abnormalities
• Polycystic ovaries
• Infertility
• Carcinoma (breast, colon, uterine cancer)
• Sleep apnea
• Pseudotumor cerebri
• Depression
• Psychological/sexual dysfunction
• Social discrimination
• Premature death

 

I would think that with this list you should be able to come up with something.  I know that it is a sick way to approach things but if using the list can get you the surgery that you want, then I say you should go for it.  I am sure that some of these can be stretched to work in your favor.  I wasn't even thinking about family history.  If your parents or grandparents had or have diabetes and you have been told that you are borderline diabetic, then I would say that counts as one.  

It might be fairly easy to claim social discrimination or possibly even depression (you may actually be depressed without even knowing it.  You should discuss this with your primary care physician.  She/he will ask you a series of questions and based on your answers you may be called borderline depressed if not fully so.

What I wouldn't do is to gain weight to meet the criteria.  One other thing might be your height ... sometimes people round up or like to say they are a little taller than they really are.  Perhaps you are really 5' 10".  This would up your BMI by perhaps one point.  

Also there are self pay options in the US and then you would only have to convince your surgeon that you are a candidate for surgery.  Mine was self pay and I had it done just north of Charlotte, NC for $11,900.  I also am aware of a few places in Texas that are similarly priced.  

Just some thoughts.

I have Cigna through my employer and. For BMI  of at least 30 to 35 WITH co-morbidities was needed for approval. 

A BMI of 35 or higher with no co-morbidities would get you approval. 

Question for you... What benefits does your insurance actually have for bariatric surgery? My insurance benefit was $4000 and then only would approve me for the rny gastric bypass which I did not want and it was $21,000 locally. So my out of pocket would have been $17,000. So I used dr umbach at blossombariatrics.com in Las Vegas and paid out of pocket for the sleeve $10,400. Do a little more checking and see exactly what hoops you have to jump through and how much out of pocket you have to pay.

ASMBS indicates best practices are the 40 BMI without comorbidities or 35 with. I doubt you will find insurance that says 35 without comorbidities is ok for surgery, but you never know.

You may find this post helpful.
http://www.obesityhelp.com/forums/insurance/4634683/Tips-for-newbies-who-are-worried-about-qualifying-for/

You might qualify or you might not. Here is how to find out.
1. get your insurance requirements/plan information in writing. Don't GUESS at what criteria you need to meet. KNOW what criteria you need to meet. If you are like me, and have a 5 year weight history requirement, you might be out of luck that way unless you appeal (which is winnable, as the link above shows).
2. get with your doctor to figure out if you have the documentation you need based on the above requirements. If not, figure out how to get it.

Good luck, you might be able to get this to come through in your favor depending on what your requirements are.

Every plan is different and you won't know unless you ask your provider specifically. Sometimes the surgeon has a wonderful administrator who will do all the leg work for you. I have been approved by the same insurance (twice!) with a BMI of 35 and co-morbidities. HBP and sleep apnea this time. The first time just the HBP and BMI was enough. We did not even know I had sleep apnea until pre-surgery testing showed it. However since then the insurance company has instituted a minimum number for the sleep apnea and the 5 year old test was below that. SOoo, we redid the sleep study and the number was up enough to qualify and I was denied. Age does that to a person apparently. During the appeal I made sure they included the history of high blood pressure too as I knew it would help my case.

All the pre-surgery testing was done for a reason. You really need to know about the sleep apnea before surgery as it can kill you post op while on pain meds. I do not like a c-pap machine but believe me I used it! Until I was off the meds anyway.

It is always worth a try to see if they will approve you. good luck.