Question:
Does Kaiser really require that you have a BMI over 50 to be considered?

I have been looking through this websites and have saw that Kaiser says that you have to be at a BMI of over 50. My doctor told me that I would have to be over 300 pounds just to be considered (which is about 300 pounds). I just need some updated information on what Kaiser requires.    — AliciasMommy (posted on October 3, 2001)

October 3, 2001
It really depends on your area as to what Kaiser's approval procedures are. However, my understanding is if you have a BMI or greater, you don't need co-morbidities. I have Kaiser - you can look at my profile.
   — Molly W.

October 3, 2001
Sorry - I meant to say a BMI of 50 or greater doesn't need co-morbidities. Your PCP doesn't sound like they have the facts. They need to go look up their policy.
   — Molly W.

October 3, 2001
My Kaiser PCP wouldn't even discuss WLS with me, told me I hadn't every really tried to lose. Fortunately, I no longer have Kaiser. But I say don't let a PCP get in your way. Demand that he/she give you the refferal and take it from there. I think if you have the right comorbs, they will cover, but they often require up to a year of THEIR classes and such.
   — kcanges

October 3, 2001
KAiser S.Cal requies either a BMI of 50 without comorbidities or 40 with 2 comorbidities. I did not have to go for nutritional education or psychiatric referral--but then I had done their Optifast program twice and it includes a behavior modification component. I also had a letter from Jenny Craig stating that I had been through their program twice. Surgery was 3 months after my first PCP consult.
   — [Anonymous]

October 3, 2001
Tiara, I have been going throught the Kaiser steps since June of this year. I have a BMI of 47 I am 23 years old. I have a PCP who is all for me getting the surgery she has been since day one. I have gone to the sleep study class and talked to the nutrisionest and had the blood work done. I have been told I should have no trouble getting approved. Just as long as they can prove I have 2 comorbidities. It also helps to write out all the diet's you have ever been on and any family history that might be related to being over weight.
   — Amy M.

October 3, 2001
Hi Tiara. My PCP told me the same thing. She said I had to be well over 300 lbs to even be considered for WLS. She was WRONG! I schooled her and I had my surgery in July. Feel free to see my profile for Kaiser's requiremenst/guidelines.
   — Carey W.

October 5, 2001
I had my surgery done in May through Kaiser (in Northern Virginia). My BMI was higher than 50, but the most important thing to show is comorbidities: Do you have hypertension? Diabetes? Joint or back pain? etc. Frankly, I found a lot of ignorance about the procedure and Kaiser's requirements when I was going through the process. I don't believe your PCP is correct about this. The most important thing with Kaiser (and I'm sure many other health care plans) is to be your own best advocate and insist on things. Good luck!
   — Mary Ellen W.

September 30, 2003
Each Kaiser area has different guidlines for qualification. In the Nor Cal area of Stockton their printed criter for referral for WLS is as follows: BMI 35-39.9 Moderate obstructive sleep apnea usually characterized by respiratory disturbance defined by apnea plus hypopnea/hours of sleep greater than 19 -or- Special circumstances as recommended by the appropriate specialist to the Regional Bariatric Medical Director or designee and approved by the Director or designee. BMI 40-49.9 -With one comorbid condition from Category 1 -or- -Any two cormorbid conditions from Category 2 -or- -Special circumstances as recommended.... BMI 50+ No comorbid conditions required Category 1 -Moderate obstructive sleep apnea with sleep disturbances deinitd by apnea plus hypopnea/hrs of speep greater or equal to 19 -Difficult to control Diabetes Mellitus -Degenerative Joint Disease of the hopos or knees -Severe GERD documented by endoscopy or imaging with failiute of standard medical treaments. Category 2 -Mild obstructive sleep apnea with sleep disturbance defined by apena plus hypopnea/hrs of sleep greater than or equal to 5. -Degenrative Joint Disease in hips, knees, ankles, feet and lumbarsacral spine confirmed by diagnositic imaging study. -Diabetes Mellitus definied as 2 fasting blood sugars over 126 -Hypertenstion which requires pharmacologic treatment -Polycystic ovarian syndrom -Cardiomyopathy with cardiology recommendation -Lower etremity edema complicated by skin breakdown, infection. Recommendation required -Ventral hernia with surgeon's recommendation -Hyperlipidemeia as per Kaiser guideline for drug treatment . -Other clinically significant conditions directly related to obesity and recommended by the appropriate specialist to the Regional Bariatric Medical Director or designee.
   — Cindy D.