Question:
I have a BMI of 40.5 with no comorbs, Will I still qualify?
I am 5'6" and 251.6 lbs. My BMI is 40.5. Do I qualify under the guidelines set by the bariatric associations? I do not have definite comorbs only aches and complaints. Have done Physical Therapy for many of these. I have seen the surgeon and my paperwork is being submitted. I just recieved a copy of it and I was not too impressed. I guess I am hoping for the best but preparing for the worst.My inusrance is tricare. Any knowledge on this would be greatly appreciated. I have searched the library. I am getting mighty discouraged as I am still scared of a denial- will be horrible. I know I will have a hard time overcoming that. Sorry this is so long. Thanks in advance. — Jan S. (posted on February 7, 2003)
February 7, 2003
Hey there- I was 266 and 5'7" and the same BMI as you and also no real
comorbidities. My insurance approved me on the first try. I believe it has
most to do with your insuance company's guidelines for surgery. It is
usually in your handbook or if you want you can call and ask. Also many
companies have web sites. Good Luck!!
— Carol S.
February 7, 2003
I have the same situation you are going through.. except Im about 2 steps
behind you. My consult is on the 25th of Feb and I am also scared. I have
tricare.. and you and I both know what a pain that can be. But They cleared
me for the consult so quickly.. I dont think you will have a problem
either.. Just know that if you are denied the first time not to let it fret
you.. they usually do.. the doc will submit it again and it should get
approved.
btw.. I have no comorbs either.. just lack of energy and general achiness.
dont give up. We are all in this together.
— heather L.
February 7, 2003
If you have a BMI of 40 or more and need to lose 100 lbs or more, you don't
need any co-midities.
— Leslie E.
February 7, 2003
Like an earlier poster said, most insurance that covers WLS will do so if
your BMI is 40; almost all will do it if you have to lose at least 100
pounds. (The others still may make you jump through some hoops.) Still,
co-morbids just make your case stronger-- and perhaps you do have some. If
your aches and pains are so bad that you have needed physical therapy, then
maybe you actually do have co-morbids. Back, knee, shoulder problems all
may qualify as co-morbids. If you've seen an orthopedist, get the official
names of your problems. For example, I have degenerative disc disease in my
back. My rheumotologist (for fibromyalgia) told me it is very common in
heavy people. Well, for many insurance companies this is a co-morbidity.
Good Luck, Beth
— Beth S.
February 7, 2003
my BMI is 64 and i have too many comorbidites to list and my insuracne
company denied me wls. some insurances will deny becuase they do not want
to pay for it, simple, has little to do with wheither a person needs it or
not! i think part of the problem is the popularity of wls now.
— janetc00
February 7, 2003
My daughter has started the beginning steps toward WLS. The surgeon told
her some insurance companies are raising the requirement to a BMI of 45 if
you have few comorbidities. Mine was 56.4 so had no problems 13.5 months
ago.
— grammie5
February 7, 2003
My BMI was just 40, exactly. I didn't have any major co-morbids besides
depression. I had a family history of diabetes and hypertension, but they
never checked (how could they?)
— jengrz
February 8, 2003
Hi there, I also have Tricare and I was approved with a BMI of 40.2. I
sent in copies of my records of ANYTHING that could possibly have been
weight-related and I sent a letter to the review board stating the reasons
why I thought I would make a good candidate for this surgery and a detailed
family history chart, which seems to play a role in Tricare decisions as
well, although they don't come right out and say it. In all, I guess I
prepared a packet of about 30 pages. You said that your paperwork had
already been submitted, but the real question is what did you submit?
Oh, also since you are on Tricare I wanted to ask if you had tried for a
referral to a military hospital. If you get the referral directly to the
hospital you don't go through the insurance company at all. The hospital
does the approval and tends to have more lenient guidelines for approval.
I was first referred to Madigan MTF in Tacoma, WA and approved almost
immediately, BUT the waiting list was two years long. So I would have
eventually had the surgery, but I didn't want to wait two years (as I'm
sure you can understand). I decided instead to go to a private surgeon and
actually used the fact that Madigan had approved me, but had such a long
waiting list, in my favor. I was approved within five days of submitting
my paperwork to Tricare. Make sure that you call them. Don't wait for
them to send you a letter (which could take weeks for you to receice once
they make their decision). Call the service center and ask every day if
they have a status for you. I wish you the best of luck and would be happy
to help out in any way that I can. Please feel free to email me and I will
send you a rough copy of the letter that I sent along with anything else
that might help.
— Nikki L.
January 6, 2004
I'm right with ya. I to am at the mercy of the Tricare system.I have a BMI
of 41.6 and I'm 5'3". I have comorbids but none of the major ones that
they seem to be looking for. Although I may have sleep apnea. I met with
the surgeon yesterday and he said he would send off his reccomendation to
Tricare but it's really up to them. I gave him my letter to submit with his
reccomendation but he said they don't need it. Everything I have read on
the net said the letter was vital. So I guess I'm now confused more than
ever. I too am on pins and needles waiting. I'm bracing myself for a
denial, it's hard to stay positive, I know. I wish you the best of luck. I
hope we both get good news....soon.
— Jillisa R.
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