Question:
I have a BMI of 35 w/ MAJOR co-morbidities and I was denied surgery, Why?
IM 24 YEARS OLD AND 2 YEARS AGO A DRUNK DRIVER HIT ME. FROM THE ACCIDENT I HAD A COMPOUND FRACTURE IN MY RIGHT ANKLE WHICH HAS RESULTED IN A SERIOUS CASE OF ARTHRITIS AND I ALSO HAVE 3 HERNIATED DISCS. IN THE RESEARCH I'VE DONE, I SEE THAT IF YOU HAVE A bmi OF 35-40 WITH CO-MORBIDITIES YOU WOULD QUALIFY FOR THE SURGERY. WELL LAST WEEK I CALLED THE SURGEON THAT MY PCP REFERRED ME TO AND LEFT A MESSAGE WITH MY HEIGHT/ WEIGHT AND I RECIEVED A LETTER STATING I DONT QUALIFY. TODAY I SENT OFF A PRIORITY PACKAGE ASKING THEM TO RECONSIDER. IN THE PACKAGE I CONTAINED MY ORTHOPEDIC RECORDS ALONG WITH MY BACK DOCTORS RECORDS AND A NOTE FROM MY ORTHOPEDIC SURGEON STATING I WOULD BENEFIT FROM THE SURGERY (AND ONE FROM MY PCP). IF I GET ANOTHER DENIAL....WHAT SHOULD I DO?? IT SEEMS THIS ACCIDENT HAS RUINED MY BODY AND THE MORE WEIGHT I GAIN, THE MORE I ACHE. I'VE BEEN OVERWEIGHT ALL MY LIFE AND ITS EVEN HARDER FOR ME TO MAINTAIN NOW BECAUSE I CAN BARELY EVEN WALK AT TIMES. ANY ADVICE WOULD BE REALLY APPRECIATED..THX, KAREN — Karen W. (posted on June 19, 2002)
June 19, 2002
Karen,
I would not worry too much. What is your weight vs. height? You can always
go to a different surgeon. It is the insurance company that you don't want
to be denied by. Check out other surgeons and then worry if they all refuse
you. Or you could call the office again and ask for an explanation and what
you need to have to qualify.
hope you find someone who will perform surgery for you. Best of
luck...hugs..
— Michelle J.
June 19, 2002
You got denied by the doc because you are a number and not a person to
them. Like the previous poster said, it's the insurance company you need
to worry about. Just make an appointment with a surgeon and have them
evaluate you that way. Good luck and God Bless!
— Kimberly L.
June 20, 2002
KAren-As the other posters mentioned, go to another surgeon. Your surgeon
is going strictly by the numbers and 35 is below the typical cut off (40).
Other surgeons will consider you on all the merits of your case. I am
actually a self pay with a BMI of 35 going to France for surgery.
— Suzanne M.
June 20, 2002
Karen, all of the foregoing posts being offered, one thing you might do is
call the insurance company and ask them. They will tell you why you are
being denied. When I was denied, the insurance company told me that it was
because the policy that my employer purchased contained a mandatory
exclusion for ALL weight control treatment of whatever kind. The key
operative words here are "that my employer purchased." That
didn't mean that the surgery wasn't medically necessary, and they agreed
that, indeed, the procedure was medically necessary, but they still didn't
pay a red cent. Check with your employer benefits representative, if you
feel comfortable doing so, as well as with the insurance company... and
good luck! Margie B
— Marjorie B.
June 20, 2002
Hi Karen- I also have a BMI of 35-36 with co-morbidities and am having
surgery July 8th. I was told by one surgeons office that they don't
"bother" with people whos BMI is less than 38 because it is such
an insurance hassle. People with BMI's between 35-39 do generally have a
harder time getting qualified. Many times the insurance companies stipulate
that the co-morbidities not only have to be "severe" but also in
my case the insurance company specified "life-threatening without the
surgery". I agree with everyone else, first contact your insurance
company and ask them specifically for their policy on WLS. Second, see
another surgeon.
— Joanie J.
June 20, 2002
GEUSS WHAT? THE PACKAGE I SENT ARRIVED AND THE SURGEON AND NURSE
OVERVIEWED IT AND THEY DECIDED THE SURGERY WAS FOR ME AND THEY'RE SENDING
ME A FIRST TIME SET UP PACKAGE....I KNEW I COULD GET THROUGH TO THEM! WISH
ME LUCK IN MY WLS JOURNEY...I'LL NEED ALL THE SUPPORT I CAN GET! THX FOR
ALL YOUR ANSWERS
— Karen W.
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