Question:
WORRIED, NEED ENCOURAGEMENT
Hi, I have been waiting for 5 months for my initial consultation with my surgeon. I have seen my PCP several times, and with her support she is documenting me trying to lose weight etc. I called my insurance co. when I first started this journey and they told me they cover the surgery under certain requirements. I think I meet them. I have a BMI of 40, I have GERD and a fatty liver, along with other Co-morbids such as depression (taking med's) and family history, back and feet pain, shortness of breath, etc. This is the thing...I called my surgeon's office to see when they were sending me my package of paperwork to fill out, and to confirm my appointment in early May and she said, "Hmmm, are you sure you have a BMI of at least 40 or 41?" I told her yes, a 40. She then said, you need to have at least 2 co-morbid's that are life threatening, or that you have to recieve medical treatment for, and you don't seem to have that. I know there are people out there with a BMI of 40 with little to no co-morbid's that get approved, but she has put this FEAR of denial in me that has me losing sleep. Am I just dreaming that this can happen for me? I am scared stiff. Thanks for any responses. I appreciate it! Michele — Michele B. (posted on March 25, 2003)
March 25, 2003
Michele, I have said it many times but people seem to not know that co-morb
means just what your surgeon office said. It is a life-threatening illness
that you are receiving treatment for. That means something that will kill
you. I told my surgeon about my arhtritic knees and fibromyalgia and aches
and pains from being over weight and his answer was Pain will not kill you.
You may end up in a wheelchair and wish you were dead but you will not die
from arthritis. But the gerd gets a lot of people approved and the bmi of
4o usually gets people approved because that means you are morbidly obese.
Keep trying and I'm sure you will get approved. Sometimes they just try to
discourage people. Good luck.
— Delores S.
March 25, 2003
You, didnt say WHO your insurance was with; but the NIH guidelies state 100
pounds or 40 bmi - its doesnt SAY with 2 thife threatening co morbids; 35 -
40 bmi ususally requires 'co morbids' Dont JUST rely on 'office' staff;
check your insurance company booklet or go on line, and check the policies
(alot of companies) have their policies on line and check it out for
yourself. and... BREATH..... goood luck.. p.s. I was 40 bmi and no health
problems... and was proved by BCBS.
— star .
March 25, 2003
I had a BMI of exactly 40 and my only co-morb was I had just been diagnosed
with diabetes, however, I had had four gestational diabetic pregnancies.
and I had borderline high blood pressure, not on medication. I didn't have
a supervised diet history. And I was approved instantly. I had HealthNet
insurance. Don't give up.
— Linda A.
March 25, 2003
The person from the office may have been asking in a general sense. The
actual criteria you must meet comes from your insurance company. As long as
your insurance covers the procedure, you should be fine. Co-morbids don't
have to necessarily be life threatening, but impact on day to day function
in a negative way.)I believe the NIH lists diabetes, high blood pressure,
sleep apnea or obesity hypoventilation syndrome, congestive heart failure
and severe arthritis of the knees and hips as co-morbid conditions that
would qualify someone with a BMI between 35-40.) Check with your insurance
company!
— koogy
March 25, 2003
Michelle - Keep your focus on getting approved. That office person may
have been just fact-finding, not being discouraging. At the start of my
journey, I COMPLETELY knew 100% that I would be denied approval from my
insurance company, BC/BS. When I didn't hear for 4 months, I REALLY knew
that they were going to deny me. It took an enormous amount of courage just
to call them to find out what my status was. Guess what? They had approved
me 3-4 weeks after my initial consult, but neither my surgeon or myself had
been notified. An oversight? Sure, but if I would have kept involved
(instead of assuming), I would be writing to you post-op instead of pre-op.
I have 5 weeks of waiting left, my date is May 2. I have a much higher BMI
than you (49 - 50) but few co-morbidities (reflux, bad knees and due to
severe snoring, possibly sleep apnea). Though it is too late to make a
long story short, I guess my point is THINK POSITIVE! And, if you do happen
to get denied, keep on trying. Best of luck to you.
— Jodie P.
March 25, 2003
I don't know how it is in your state but in the state of Alabama BCBS is
the main insurance provider (80% of the state). Most insurance companies
who do not exclude bariatric surgery require only a BMI of 40 because this
is what the N.I.H. (National Institutes of Health) criteria are. To have
co-morbid conditions in addition to having a BMI of 40 or above is just
icing on the cake, so to speak. I can't guarantee that your insurance
company has the same criteria but most of them are similar in their
standards to qualify under medical necessity. Hang in there. I think the
office person was simply collecting data and probably didn't mean to alarm
you. You'll make it!! Best wishes!
— ronascott
March 25, 2003
Michele,
Make sure that your pcp documents everything that is wrong with you. If
you have pains, go and see the doctor. It is then documented. Get a sleep
study done if there is a possibility of you having sleep apnea. I had a BMI
of 39.3 and several co-morbids but none that required medication. They just
were recorded by my pcp as my starting to develop them. I had no problems
getting approved. The baseline for having the surgery is a BMI of 40 with
no co-morbids. A BMI of 35-39 requires the co-morbid conditions. Don't pay
too much attention to the person you talked to. Ask to talk to the person
that submits the paperwork to the insurance company. She will know what
they need for approval. Good luck!
— Sandy P.
March 25, 2003
I would listen to the insurance folks over the surgeon's office. I had a
BMI of 40.something and very minor co-morbids, none life threatening and
was covered on the first call. Have you checked out the sectio here called
"insurers"? You can read about others with your same insurance
and see what their experiences were. Good Luck!
— Carol S.
March 25, 2003
Michele sometimes when a person has had a rough day, are not in a good mood
that want to make you feel like them. So keep steadily and stay focus on
what you need to do to get yourself approved. God is in control, and no one
else.
— julie B.
March 25, 2003
Just wanted to share with you, I was worried the hold time from the time I
made my first appt. until I had everything in waiting on insurance
approval. You are lucky in the because you have a PCP that supports you
having this surgery. That is the biggest problem, if your PCP's behind you
that's a big plus for the insurance company. As soon as I found a
supportive PCP, it was all down hill. They said 30 business days, I called
back after giving them some extra time they called insurance co and got
approval that same day. Yippee.
surgery date 04/02/03
— deniece M.
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