Question:
Is being over 100 LBS overweight, and a BMI over 40 'medically necissary'?

I am over 100LBS overweight, and have a BMI of over 40. I do have some co- morbidities too. But I don't have hypertension, or diabetes, or mangled discs, etc. The ones I have seem minor in comparison. (Asthma, joint pain, high cholesterol, low back pain, sciatica, etc...). Would I be considered medically necissary by my insurance company? Granted my insurance is different from yours..(CMS AHC), so would I qualify under YOUR insurance? I am worried that I won't be considered 'medically necissary' enough for surgery. Am I worrying too much?    — [Anonymous] (posted on April 19, 2001)

April 19, 2001
Hello. You need to first check your company's HR booklet and see if they have a clause. I have Highmark Blue Cross Blue Shield and the clause under the Traditional Plan reads "We will not pay for treatment of obesity, except for surgical treatment of morbid obesity when weight is at least twice the ideal weight specified for frame, age, height and sex." I qualify with out comorbidities because I'm 320 and should be 150. Hope this helps.
   — Kimberly L.

April 19, 2001
Hello, I'm just starting through this whole process but my insurance is IBG and it has a clause too. To be medically neccesary you have to be 100 lbs. over weight. So if that's the case I will qualify, im 317 and my BMI is 58. Good luck if your insurance has this clause I would think you would qualify.
   — Peggy G.

April 19, 2001
I am 8 days post op and my BMI was exactly 40. I did have a few comorbids but I didn't need them. As long as I had at least 100 lbs,40BMI and 2 medically supervised diets is all I needed. For me the comorbids are a must if BMI is 35-40. Best wishes on this journey!
   — Linda M.

April 19, 2001
Medically necessary with my insurance meant it didn't care if you were six hundred pounds overweight--you NEEDED to have medical reasons/problems other than the weight--diabetes, hypertension, joint problems, etc. I had to get my doc to say that without the surgery, I would die.
   — [Anonymous]

April 20, 2001
Yep, you're worrying too much. You didn't mention anything about seeing your PCP for a referral. If you haven't seen the doctor you'll never know if he feels it's "medically necessary". Sounds like you'd quality to me. Check out the website the American Obesity Association.
   — Lynn E.

April 20, 2001
You qualify and your comorbidities may seem mild now but can only get worse if the weight isn't lost.
   — Lisa B.