Question:
BMI is at 36. I need a letter for ins. co. from pcp that will qualify me. Help!

I have asthma, joint pain,Gerd, and possible sleep apnea. My BMI is 36. How do I make sure that my pcp's medical necessity letter will fly with my ins. co.? Should I give him a list of what to include in the letter? Should I have him include my family history? My grandfather died from esophigal cancer that started out w/ reflux. Help, I don't want to be denied coverage. I would love to have this surgery and start my new life, happy and healthy. Thanks : )    — Nickie C. (posted on December 15, 2002)

December 15, 2002
The first thing you really need to do is make sure you know what qualifications your insurance company has. Don't take what they tell you over the phone as gospel, though. Make them get it to you in writing. They should be able to send you a copy of the part in your policy that deals with WLS. You should also be able to get a copy from your HR dept. You may qualify based on what you've listed above or your insurance may have further qualifications for the surgery.
   — garw

December 15, 2002
Something that won't fly with an insurance company is "possible sleep apnea". They need it documented that you actually have it. I would get a sleep study done before attempting to get ins. to cover. The diagnosis of sleep apnea was THE THING that got me approved. My insurance co. (Kaiser) considers it a "life-threatening" co-morbidity, and with my lowish BMI of 40, I needed at least one really bad co-morbidity. Hugs, Joy
   — [Deactivated Member]

December 15, 2002
I am not sure you qualify for this surgery. Thay like you to have a min BMI of 40 and around 100 lbs overweight. WHat are your stats? Height and weight? Have you tried other methods of weight loss and failed. I am not saying you shouldn't have this surgery, but I just think its for people with higher BMI and more weight to lose that have exhausted all other options. Good luck!!!
   — Jody Diou

December 15, 2002
Every insurance co is different. I was very surprised at the comords my insurance required for over 35 but under 40. Unless you have 3 of the biggies over 35, they are not going to approve, and this is from an insurance company this is more WLS friendly than most. You need to go through the list of comords and try to find out how your insurance company ranks them in importance/significance. You could have 5 of them but if they are minor, they don't really count. Sleep apnea is a biggie and you should definitely get a study done. I don't know about asthma, but with my insurance co. joint pain (not arthritis but simply joint pain) and GERD were minor comords.
   — susanje

December 15, 2002
Thanks for all of your input. I do appreciate anything that might help in my situation. Please feel free to look at my profile. I have a list of about 10 different diets Dr. supervised and otherwise. I am scheduled for my sleep study on the 30th of this month. Hope I got it or sounds like I am going to be in big trouble.
   — Nickie C.