Afraid I won't qualify for surgery

I figure some fellow "lightweights" probably had to deal with this as well. I'm going through the process of gathering info on the two local hospital's bariatric surgery programs, as well as what is needed for my insurance, and despite a BMI of 38.5 I'm coming up against some issues. Since I'm below a 40 BMI I need at least one qualifying comorbidity for insurance, and two for one of the hospitals.  I had my doc do some labs to test for the usual suspects (diabetes, hypertension, high cholesterol). Got none of those. Shocked the heck out of me! So then he sent me to get a sleep study. I do snore terribly and wake up a lot, so I thought maybe apnea. Nope, just a snorer. I saw my orthopedic surgeon about the continuing pain in my knee after ACL surgery two years ago thinking it might be arthritis. Nope. He says it looks fine, just something I'll have to live with.

Why am I so physically healthy?!? I should be falling apart after all the years of poor diet and little exercise! The only thing that is really wrong with me is my depression and anxiety that I've had since childhood. Anybody know if that is considered a comorbidity? It is definitely worse as I've gained weight and doesn't respond well to medication. Anybody have to get creative or sneaky to get approval for surgery? Should I just try to gain weight until I reach a 40 BMI?

it varies some take depression as a co-morbidity and some dont. On the lists of things that WLS can cure or make markedly better is depression. I would definately try to see if that will qualify you with one or both hospitals, then you will only have to come up with one more for that hospital that requires two. I dont want to be someone to help you cheat, but I think I can help. Message me and we'll talk. For the band, which I do not recommend, they are setting up guidelines now where you can be a 30 BMI with a co-mrbidity and get it, or just have a BMI of 35. I had to go the self-pay route after trying 2 1/1 times, but wasnt able to get it over stupid ins B.S. I qualified and went through ALL the tests and then my state contiuation ended through an old job and they wouldnt finish and just do the surgery..the *******s dropped me! Since you live in NC, you may or may not know this, but as of I believe Oct 2010, our state decided to not cover any WLS anymore, even with people like me who have like 4 maybe 5 co-morbidities! But, anyway, if you want we can talk more, I be glad to help a fellow N. Carolinian! (haha) P.S. luv your avatar

Wow... surgeons are sure different.  Mine was very helpful and the whole Bariatric Team was on board when it came to helping somebody get approved.  They all knew I needed the surgery because of the roller coaster weight loss / weight regain plus some I'd been on for decades.  Each one of them put in their notes that I had sleep apnea (based on my description of waking up to a terrible noise and looking around to see which dog had done it just to see that they were all sound asleep. No sleep study required.)  I did not have diabetes, but based on a sister & father who were borderline diabetic (controlled by food) and an honestly coincidental half package of oreos the night before bloodwork, my sugar was 99 and most definitely pre-diabetic, which merited listing.   The pain in my knees that caused me to not exercise or walk much do to the pain was listed as an additional complaint.   Hypertension in Mom, high blood pressure in Dad, congestive heart disease in Mom... all were listed as "running in the family".   So, all these things were used as back up information but, the bottom line was my BMI was borderline and I had to do my part to get it up over 40.  That was never requested directly but I knew it was what was needed in order to get past the insurance companies without them demanding further testing & diagnosis of any of the other items listed.  My surgeon refuses to proceed with surgery when anybody has binged and gained 5 lbs. or more from the time of the pre-op appt. to the time of surgery.  That makes sense.  However, he verified that the weight at the time of the pre-op appt. was the weight (and BMI) that would be submitted to them for final approval.  I did what I had to do to get my weight from 216 to 224.5 and BMI to 40.5 and it all went through like a charm.  One of my happiest days was when I had those numbers at that pre-op appt. and I asked the doc if I could start losing now.  He grinned and said, absolutely, the more the better.  I immediately went home and kicked off my boots, changed out of my winter clothes, emptied my pockets and quit eating all the crap!  LOL   I lost 20 lbs. before surgery, which made it easier for them to maneuver around in there and I think might be one reason things have gone without complications for me.  (knock on wood)

If you will find out which weight/BMI is submitted for final approval, you will know what your target date is for having a BMI over 40, even by a little, it must be over 40 and not just a 39+ number rounded up. 

Follow up on what criteria is required for depression to be a co-morbidity too.

You can do this!

Wanted to wish you good luck and do talk to us via PM on how to get through some of the road blocks insurance throws up in front of us. At some point you may even decide you need to go out of country and folks can point you to good surgeons, not ones that will take advantage of you. Hang in there. Go Heels!

--gina
   

I was over the magic number for my visit that counted but I do think that NC medicaid is no longer covering WLS.  My insurance still does to my knowledge, state employees BCBS.

My insurance did require a Blue distinction center and that slowed me down a bit as I had to go 1.5 hrs away into SC to get the insurance to cover, not to my local group.  But they handled all the insurance and knew exactly what I needed to do, what would and wouldn't qualify.  Starting with a group may be a big help in your quest to determine what your next steps will be.

My only comorbidity was acid reflux. I was actually surprised that I qualified because of it. Most others I know got through on the sleep apnea diagnosis.

Good luck on your journey!

Thanks everybody for the advice and encouragement. I have BCBSNC through work so I know they do cover most WLS. Not the sleeve, which is what I first thought I should have, but oh well. I haven't actually met with the surgeon yet because both programs have a pretty big application fee that isn't covered by ins, so I wanted to be sure I wouldn't be wasting my time before I spend that money. I'm going to contact the ins company and ask for clarification on a few policy issues. One possible qualifier they list is if your obesity has caused job loss or you are in danger of losing your job. I work for my family and my job is physical so maybe I can get by with a letter stating my job is in jeopardy. Probably not that simple, but worth a shot. I'll also starting eating late night Ben and Jerry's to make it over the 40 mark before my next doc appointment. I think I calculated about 8 lbs I would need to gain.

Again, thanks for the help. I'll keep you all updated on my progress.

p.s. - the avatar is my beautiful hound dog Lula taking a post-nap stretch. and yes, GO HEELS!

Quick update. Spoke to BCBS and the person there said they pretty much go by whatever is in the doctor's notes and records. So if I report to the doc that my job is in jeopardy because my knees and back hurt too much then that counts. They don't even want a letter from my employer. What the heck?