Group Health advise needed

So I got a letter today telling me I don't qualify to enter their program because my BMI is low enough that I have to have another "problem" as well such as sleep apnea, diabetes etc.. you know same old story... My BMI is 45.6 -- and I have to have another illness too??? Here is what I think -- this denial is just an automatic thing they do when they don't see other issues along with weight - I'm not all that convinced they saw my BMI... I'm going to my doctor again on the 5th and to get referrals to be tested for all the conditions they listed - save blood pressure since I already know its low... I might have sleep apnea - but not convinced that I do... its my best hope really - I'm borderline diabetic but that doesn't seem to count for much according to their letter. chronic back pain and migraines don't seem to count either... that is so frustrating! I'll put in for an appeal after I get test results back... has anybody else ever had group health and got a denial right off the bat - appealed and was approved? I know a lot of folks get on here and ask the same panicky question - and I've read on the insurance helps on this site - I guess I just want some advise - insights... I really thought my BMI was high enough and I was sitting here stressing about having to do a six month monitored diet!! HA! I never dreamed I wasn't ill enough... thanks for any helps. Sarah

I was approved based on my BMI (it was over 50). However, needing gallbladder surgery and on the waiting list for the Lap RNY, Group Health was going to do them as two different surgeries. I decided to cut the 8 to 10 month waiting list and went to Mexico. Of course that costs, it was $14,600 for the lap RNY and another $850 for the gallbladder. -Pam

I talked to Harriet yesterday and mentioned the "rumor" that GHC was quick to deny. She said that they are actually approving people left and right! So what's up with your denial?! I actually work for group health and researched all the info possible on our internal website and I swore they only require a BMI of 40+ without any co-morbs. I think I even have some of the paperwork here.....oh wait, here it is.... "Has one of the following: *The patient has a BMI greater than or equal to 50 OR *Has a BMI of 40-49 with documentation int he medical recrod of one or more of the following co-morbidities: *Sleep apnea with active treatment *osteoarthritis by x-ray *Hypertension *Diabetes *non healing venous stasis ulcers or recurring cellulitis" Sorry, I hope this shed some light but looks like you "need" to gain a few pounds! Which is crazy!

Yes that sheds light - that is the info I was wanting to see directly - not just in a denial letter... And gain a "few" pounds?? I played with the BMI calculater and I'd have to be about 310lbs to get there (I'm 276 now)--I can't even imagine weighing that much... maintaining weight loss is hard and lately even losing weight is hard -- I'm sure if nothing else proves to be wrong with me I'll eventually get to 310 - in the next ten years... I just want to sit and cry... I cannot believe I'm not sick enough! I have to sit and wait to get sicker for GH to do anything? I have to wait for heart disease and wait for arthritis and wait for high blood pressure... God knows I'm praying that I have sleep apnea!!! This is insane!

Have you had your height measured recently? All these years I thought I was 5'6" and come to find out, I am only 5'4"!! That changed my BMI big time. From the sounds of it, I think you have sleep apnea. You have all the same symptoms I had before I was tested. I sleep with a CPAP now and feel so much better. Good luck! Lori

Hi! Great suggestion Lori! I, too, always thought I was 5'6" so my BMI was not up to 50, but at last summer's physical I found out I was only 5'5", so I only had to weigh just over 300 to qualify w/o co-morbidities (at GHC). But when I was tested, I found out I had sleep apnea, too! Unfortunately, I don't feel or sleep any better than before. I guess I need to call the Dr. and see if I need a higher setting. Apria just set it at "7" and told me that was an average place to start, but I don't know when or how or if to change it. I had a home study done and I think they should re-do the test while I'm using the CPAP so they can see if it helps. It does prevent me from snoring, so SO is really happy and reminds me to use it! Good luck! Mari

Mari, Having had 3 sleep studies in the last 10 years I am a littled alarmed that Apria arbitrarily set the pressure on your C-PAP at 7 because that is the "avearge place to start"! I can tell you that a home study is not a sufficient study to determine if you have a sleep disorder. Sleep disorders range from apnea to narcolepsy to restless leg syndrome to insomnia and more. Only a fully operational sleep study lab can accurately diagnose a sleep disorder in an overnight stay at their facility. They have all kinds of sensors they hook up to your body....face, eyes, scalp, mouth, throat, chest, abdomen, legs etc to see what is going on with you when you are sleeping. They measure the O2 Saturation in your blood, your heart rate, blood pressure, depth of sleep (there are 4 stages), REM, the number and degree of your arousals through the night, your leg movements and on and on. They also 'watch' you sleep over closed circuit TV. Once a diagnosis of obstructive sleep apnea is made, your sleep Doc should "prescribe" an appropriate pressure for your C-PAP. It is my understanding that the pressure setting is an actual "prescription" as there are dangers in having a pressure setting that is either too high or too low. Too low and you don't get the oxygen you need, you can suffer a stroke or just die in your sleep. To high and that can create an embolism that can kill you. My first study revealed "severe obstructive sleep apnea" (90% obstructive, 10% neurological) and my pressure was prescribed at 19. The study showed I never got below stage 2 sleep thus I did not dream or rest while I was asleep. I had more that 300 episodes of apnea/arousals in an 6 hour period of sleep and my O2 sats got down to 40 % at least one time during the 6 hour study. My Docs were shocked and said I was a prime candidate for a stroke. I do believe that my O2 deprivation over the years has contributed to a severe short term memory disfunction. My first night with a C-PAP, done as the second night of the sleep study in the sleep lab, provided me with the best nights sleep and rest than I have had in years. I actually felt rested and alert the next morning after spending the night in the lab on a C-PAP machine with a pressure settting of 19. If you have sleep apnea, you need to insist on a full sleep study in a lab to get a proper diagnosis.

OMG - Mexico? Weren't you scared at the quality - I hope nobody thinks me racist or anything for wondering - but I'd wonder if ppl say you can't drink the water I'd be concerned about the quality of health care - I must be wrong because you aren't the only one whose gone to Mexico.... GREAT for you that it turned out okay - You are a brave person and the price wasn't so bad either - in the US I think it almost runs twice as much!

Yes, in the US it easily runs twice as much. The hospital I was at was first class (San Jose in Monterrey Mexico) and it was CLEAN! I had great care and was pleased with the experience. Mexico isn't for everybody, but not willing to wait the 8 + months minimum to get the surgery. I'm 51 and not interested in wasting my time when the lifestyle changes WLS provides (yes, I know, it is just a tool) will allow me to do so many things I enjoy while I still can enjoy them. This winter I'm going skiing. I haven't gone for years since 1) couldn't get large enough ski clothes and 2) when I fell I couldn't get back up. -Pam

I know what you mean by lifestyle changes - I'm only 33, and I've changed what I eat, how much I eat and when I eat and I'm still maintaining 276. The nutritionist says my body is on starvation mode... I'm sick of all the effort I put into eating... and getting no results... let me put that energy into and have it make a difference is how I feel - which is why I'm going for surgery. Like I said before - it must be worthwhile since so many are going to Mexico for surgery. I might look more into that if it comes down to being able to afford to pay for it myself... my cousin had hers done in Germany by German doctors (she is military) and I still just worried about it for her sake - I'm not a risk taker and that is why the decision to do the surgery was such a huge one for me. Did you have to wait long - is there a long waiting list? Thanks for sharing your experience and advise - I truly appreciate it!