Lightweight, concerned about insurance

I've already checked with my insurance and they do cover WLS. I didn't get into details, so I dont' know exactly what they cover--I plan to call them this week for clarification. I am so worried that I won't get approved.

My current BMI is 38 and I have high BP, pre-diabetes, insulin resistance, asthma, severe sleep apnea(on CPAP), severe arthritis in knees and feet. I was on a medically supervised weight loss plan from late-2009 to Aug 2012. During that time i lost 55-lbs and got the BMI down to 30 but I couldn't seem to break the 30 barrier. I have gradually regained 47-lbs back and I'm so demoralized. I know that I cannot lose this weight without assistance. I have been in the obese range since my last child was born 18 years ago. He is severely mentally handicapped and autisitic, which has cause incredible stress in my life. I'm handling my stress well now, but the eating is Off. The.Chain.

When they say you have to have a BMI of 35 for 2-5 years, how does that work? My BMI has gone from 33 to 35 to 40 to 30 and back up to 38 in the last 5 years.  I have gained and lost and gained and lost. Will they look at my history and think "well, obviously she can lose the weight on her own, she doesn't need surgery." But i think I do! If I could lose it and keep it off I would  done it years ago.

It all depends on your insurance they are all different requirement. You should be good. as a rule it is BMI of 35 with 2 co morbidities or BMI of 40 with or without comorbids. Just don't get below the 35 BMI. Your surgeon may also have requirements of his own too. Even if for some reason you do get denied you can always appeal or send them additional info. Best of luck with your begining journey.

Your story sounds a little like mine: BMI of 38.8 at point of submission, having had worked on weight loss with my PCP since 2008. I had been successful, yes, but only to a point. I had comorbids that would qualify me. I was unfortunately successful enough to be below a BMI of 40.

Insurance (UHC) requirements were BMI of 40 + 5 years previous diagnosis of morbid obesity. Nobody cared that I had worked with my doc. They didn't want supervised weight loss. All they looked at were numbers. I was denied on first submission, as well as first appeal. My doc's office staff told me there was nothing else they could do for me. 

I hired Walter Lindstrom's office to handle my appeal from there. My next and final step was to my husband's employer. Lindstom's team put together a great written argument that told them exactly why their criteria sucked (in so many words), and they shepherded it through the appeal hearing. I came out on top. Not only that, but the medical director realized, based on the strength of the argument made, that their criteria was outdated and they directed UHC to change it. So, hopefully this will open the doors for others.

My surgery was last Wednesday. Once we got it all established that this was, in fact, medically necessary, everything evened right on out and the delay at that point became my desire to finish a big project at work before I went on leave.

What I learned: 

Insurance companies have written requirements that they must follow. Find out the details on yours. If it says 35 with comorbids and you can present all of that clearly in your first submission, you're golden. They won't deny you just because they can, or just because "they deny everyone on the first submission". That said, they will also not attempt to connect any dots in your file. If anything is out of order, they'll deny it because it doesn't meet their criteria (so far as they can tell).  Get a copy of the current requirements in writing and keep it near and dear to your heart because these are the rules of engagement.

Start with an official validation of your height and weight from a physician. My height varied by 2 inches in my various records I had pulled. Start with one - your current one - and put that forefront. Base all BMI calculations from there.

If you're denied, FIGHT IT! There are due process steps that are laid out for appeals. Utilize them. Consider hiring an outside advocate if you don't feel you can devote the time/attention that a well-planned appeal would require. Yes, it was an expense, but it was less expensive than self-pay, so it was worth it IMO.

Be in it for the long haul. If you should happen to wind up in the position of appeals, it will seem like everyone else and their dog are approved in 2 minutes or less. And, it will suck. Don't underestimate the amount of time it may take (5.5 months, in my case). Always remember you are doing this for your health and that even if it takes 5 months to get it approved, you are still doing it.

I sincerely hope you have smooth sailing, but I am here to testify that you can survive and win appeals. Keep in touch and let us know how it goes.

Laurie