Question:
Insurance ONLY considers pds. and NOT BMI.....

My insurance is Boeing BC/BS PPO. I have been just under 100lbs. overweight for several yrs. and just over for 3 yrs. I have to show being over 100 lbs. for 5 yrs., nonconsecutive. I have several comorbidities but they won't budge to approve my surgery. My surgeon has appealed to them but no luck. My surgeon says that in all the yrs. of doing this surgery, they have Never heard of a company not considering BMI. My health is deteriorating and I need this surgery. Any suggestions or ideas? Has anyone heard of a company doing this? I'd like to also know how anyone with similar weight (at or over 100lbs.) has dealt with this issue. Thanks!    — Sarah O. (posted on December 9, 2002)

December 9, 2002
The reason BCBS is asking for 5 years meeting the conditions is to make sure that this is a "disease" you've been fighting for a while. (As if anyone would do the surgery for fun). Have you had a BMI of 40 for at least 5 non-consecutive years? Then, I would make an argument that BMI is the better criteria. If not, but you've been at least at 35 plus co-morbidities, argue that this is a good criteria, too. <br> I would look carefully at the wording in the policy. Does the policy say that WLS is allowed only in the case of 100 pounds, or does it use the words "medical necessity"? In other words, is the 100 pound requirement in the policy, or is it in their interpretation? Ifit is their interpretation, appeal again, and keep going up the ladder. Call to talk to someone on appeals, so that you can address the appeal directly to them. Then address the following issues in the appeal: (1) The definition is antiquidated and (2) it is discriminatory. First, make the point that now Morbid Obesity usually is defined in terms of BMI, or BMI and co-morbidities, so that BCBS is out of step with the time. NIH, the National Institutes of health, describes morbid obesity as a disease. Get hold of the definition-- you can find it on the web-- and show that you meet the NIH definition. Also point to Virginia and Maryland State laws to show that BMI and co-morbids are allowed. Check to see if California also has such a law, since I assume you are in Oregon, and California is closer.<br> You should argue that it is outdated and discriminatory for weight to be used. BMI is used as a ratio: because people with similar BMIs have more similar statistics than those with the same amount of extra weight. Use of weight, alone, discriminates against small people-- usually women. weight alone is discriminatory. After all, the ones who are not 100 pounds or more overweight, yet still have BMIs over 40 often are women. So, it is much easier for a man to get approved-- even if he has a BMI less than 40-- than a woman who is short and small boned. Good luck!
   — Beth S.

December 10, 2002
Good info for you by previous poster. I only want to add that it's not clear whether you have formally appealed the decision or if your surgeon just called or wrote them a letter. There is a formal appeals process and you should use it, because your case usually then goes to a different person in the system, who may reverse the original decision. Best of luck!
   — Arlene S.

December 10, 2002
Ok, Insurance companies dictating care again!!! No suprise Here! What are your comorbids? Do you have asthma, trouble breathing, sleep apnea, aching joints, knees, and back pains? Check out this website to write your letter... http://www.obesityhelp.com/morbidobesity/m-ins-lettermn.phtml I am in the first sages and just hoping to have surgury. My BMI is 35, so I'm searching for co-morbids like wild fire. My blood work is too good and my presure is good too. I did just get diagnosed with asthma yesterday though and got a RX for an inhailer and talked to the surgeons office that I'm hoping to use, (who also has a special procedure that is guaranteed not to streatch out) and they said that asthma is a comorbid qualifier. I also am going for a sleep study on Dec. 30th. any pains in your knees and joints may be osteoarthritis. See a chiropractor, you are the only one who can gauge the amt. of back pain you have.. If you have any questions, feel free to call Barb at Dr. Sapala's office, (that is the surgeon I am hoping to use) the # is:517-782-0057. She is the sweetest thing and I'm sure would be happy to answer some questions for you.. Good luck on your approval! I'll be saying a prayer for you... Sincerely, Nickie
   — Nickie C.

August 21, 2003
Boeing Traditional BC/BS PPO is a self insured insurance meaning that Boeing chooses what the rules of the plan are and Regence administers it..... i'm in your same boat
   — nicoleinseattle