kellymiller333

weight gain on purpose? whats med. necc?

21 posts in this topic

I have three questions, hoping someone can help me..

1) Insurance says they will pay for if "medically neccessary" what does that mean? Does it mean that if I'm at BMI 40 that's medically necc.?

2) I am right at BMI 39-40, I have read people say to start the supervised 6mo diet right away just incase insurance changes thier mind about it down the line, I am worried that the insurance is going to want me to go on the 6 month diet and by then (if I follow it :) ) that I will go under the BMI that's allowed by the insurance co. Do they go by your weight when you first go in?

3) Has anyone try to gain weight to make sure theyre at BMI 40 or above??

AGAIN, THANKS FOR YOUR HELP!!

Share this post


Link to post
Share on other sites

Usually insurance goes off of your BMI from when you first start the diet. I personally didn't need to gain any weight since my starting bmi was 52 (YIKES!) but I had surgery in Dec and my BMI is now 45 :) I would call your doctors office and find out more information regarding what BMI reading insurance will go off of in order to qualify for the surgery.

Share this post


Link to post
Share on other sites

My BMI wad 39-40 and I ended up being denied because my BMI was under 40 AFTER the six month diet.

However, I appealed and was approved -- a one time exception.

The insurance companies just do whatever they want whenever they want. I couldnt get a straight answer from any of them when I asked your same question when I first started looking into the surgery.

Ask them...but, you may not get a straight answer either.

Share this post


Link to post
Share on other sites

I was right near the minimum...I wore layers, boots, my cell phone and ate and drank a lot. I ended up being 19 pounds (surprised me) above where I needed to be for my 35 BMI. Yes, you need to stay above the minimum BMI (35 or 40) for the entire 6 months until you get approved. You can NOT gain weight after you start (I've seen people denied for even gaining a pound). For most insurance you are expected to be a 'failure' at the 6 month diet, which means that you're only to lose 5-10 pounds approx. (which is why many of us call that the 'unweightloss program'). Some ins. companies or docs require a certain % of your weight.

The best person to get this all confirmed by is the insurance specialist (or billing person) at your surgeon's office as they deal with the ins. companies every day. They're not allowed to tell you not to lose weight, but if you phrase the questions correctly and listen, they will tell you. Good luck!! -BG

Edited by Band_Groupie

Share this post


Link to post
Share on other sites

Before I had my band in 2006 my surgeon told me I wasn't a candidate because I wasn't overweight enough. For the next few months I ate like a ravenous animal and put on 20 lbs. and then I was good to go. Everyone thought I was nuts but I did what I had to do!

Share this post


Link to post
Share on other sites

Kelly - I don't know what your insurance cover requirements are but do you have any co-morbidities that could help your case?

Share this post


Link to post
Share on other sites
Corrine,

Family history of heart disease, two sisters had the GB surgery so runs in the family(?), mom has diabetes 2, not sure if they'll consider that.

My gynocologist told me I had a cyst on my right ovary, so she put me on birth control (double dose) to try & shrink it but my blood pressure hit the roof (documented). I called her told her so she lowered, just wondering if that would be a factor also. BTW, I have BCBS lumenos. Thank you for your imput! Kelly

Cardiovascular disease can be heredity but the good news is that it can be prevented by maintaining a "normal" weight, exercise and a healthy eating programme.

Type 2 diabestes can run in families - around 40% of siblings and approx 1/3 of the children of type 2 diabetics will develop it. Obesity increases your risks of developing type 2 diabetes enormously of course.

As far as the ovarian cysts are concerned. Obesity affects our hormones and cysts, endometriosis, fibroids etc. are common in the puffier woman.

You need to talk with our doc about these and any other issues s/he feels would support your claim for WLS.

Share this post


Link to post
Share on other sites

IN MY OPINION, There is no reason to have to gain weight to qualify for a surgery. This is a hot-button topic and it is going to get you some very emotional answers.

I would see if you have any other co-morbidities that contribute to your 39 bmi, DO NOT GAIN WEIGHT. It isn't healthy and isn't the smartest decision.

Share this post


Link to post
Share on other sites
I have three questions, hoping someone can help me..

1) Insurance says they will pay for if "medically neccessary" what does that mean? Does it mean that if I'm at BMI 40 that's medically necc.?

2) I am right at BMI 39-40, I have read people say to start the supervised 6mo diet right away just incase insurance changes thier mind about it down the line, I am worried that the insurance is going to want me to go on the 6 month diet and by then (if I follow it :) ) that I will go under the BMI that's allowed by the insurance co. Do they go by your weight when you first go in?

3) Has anyone try to gain weight to make sure theyre at BMI 40 or above??

AGAIN, THANKS FOR YOUR HELP!!

I would say that it IS necessary to gain a controlled amt. of weight to become approved. I think people find it to be a bad idea because it sounds like you're just "gaining weight to get the surgery", but your not, your gaining weight to get approval for the surgery and they ARE different. The fact is that Insurance is very strict when it comes to borderline making the cut, and if you dont make it, no matter how close you are to the cutoff, theyll deny you. I just believe that because you are denied, doesnt mean you dont need the surgery. You need the surgery regardless of the 5-10 lbs you are under their limit, so you jsut have to do what you have to do for them to approve. While its not good for the short run, in the long run, i think gaining 10 lbs to be approved is a damn good investment, and once your approved, you can go on the pre op diet and lose twice that much anyway, and then post op, you'll lose 10 times that..lol :rolleyes:

I_Will_Survive likes this

Share this post


Link to post
Share on other sites

This whole thing of defrauding the insurance company is just unseemly to me. Come on, think about it, the insurance people are people just like us and they know what the deal is. The guidelines are just that, GUIDELINES, everyone is different and there are instances when a patient is granted approval even when all the golden guidelines are not "met". It all goes back to what the PCP recommends, not the surgeon. This is the sort of behavior that drives me nuts, I can't condone it.

Share this post


Link to post
Share on other sites

First of all, dont judge anyone without walking in their shoes! Think about it what would you do? Put yourself in these shoes! If your right at the cut off BMI, would you make sure you make the guidelines or just be denied and go on fat & depressed & unhappy (which you would probably gain the weight anyway)?

Share this post


Link to post
Share on other sites

If you are addressing me, then I am qualified to speak because I am "walking in those shoes" and I am also a nurse case manager and for insurance. Therefore, I know the competing priorties, but I think it's just unethical to manulate the system, because really you're not. If the patient will benifit from surgical intervention , then the owness is on the PCP to make the case, speak to the insurance medical director or even get a 2nd opinion. It's my opinion, I certainly understand the anxiety of the patient and I am the 1st person to fight and DEMAND the care and services that are due. I don't think it's necessary to change or "fudge" data to meet a guideline. If you need the surgery, then you should get it, the guidelines are just numbers. I can either read these comments and ignore them, or respond. I can't turn off my professional opinion.

Share this post


Link to post
Share on other sites
First of all, dont judge anyone without walking in their shoes! Think about it what would you do? Put yourself in these shoes! If your right at the cut off BMI, would you make sure you make the guidelines or just be denied and go on fat & depressed & unhappy (which you would probably gain the weight anyway)?

This is crazy talk. Um, we are all fat... MOST of us qualify(ed) for WLS. I understand that you are misreable being fat.

The term I hate most on here is "you don't understand what it's like to be fat" ... yeah, totally *calls the men in white coats*

Maybe when you are at the bmi high enough you should reconsider this surgery. Do not purposely gain weight though, it does nothing GOOD to your body. And if you choose to "add weight" with ankle weights/coins in your pocket, know you are risking insurance fraud.

Share this post


Link to post
Share on other sites

umm maybe you didnt understand what I wrote jersey. Put yourself in that particular situation that I explained. I really doubt anyone can say they wouldnt try to gain a few pounds. Come on, its a matter of not taking a poop before you go to Drs.! As far as the insurance co., (just from reading posts here) they lay out all the guidelines, then you go in for the approval they may or maynot change their minds, may or may not require more info, may or maynot accept your beginning weight. #%$? fight fire with fire!

I_Will_Survive likes this

Share this post


Link to post
Share on other sites

I am with United healthcare choice I went straight through the insurance to set everything up. This is what she said to me. One of the qualifications is to be at or above 40% BMI. I do need to go on the 6 month supervised plan. I did ask her some concerning questions about that because I was frusterated that If I was successful with the weight loss would they not approve me? The lady said that just as long as I am still at or above 40% after the 6 months is over then I will be good to go. However If for some reason it is below 40% and I am succeding in the diet just stick with it and see if I can still lose the weight. But if I fail at that and end up above 40% again I can call the insurance back and get the ball rolling again and not have to do the 6 months again because that supervised diet that I was on is good and on record for 2 years.

That is how my insurance is. I cant speak for any other.

Share this post


Link to post
Share on other sites

First and foremost you have to have a conversation w/ insurance to know for sure, search the forum and see what other people's experiences have been.

Plain and simply,how most of us on here would go about gaining weight is unhealthy - eating sodium and fat laden stuff. It can damage your liver and kidneys in the process of trying to get surgery.

"Luckily" I am beyond fat enough for surgery, but keep in mind that insurance companies have such stringent rules because people do game the system. I understand the difficult decision, if you do go down that path try to be healthy about it - lift weights, drink and eat the right things to gain weight "healthily"

You don't seem to have a problem with it, but if you have hypertension, are prone to stroke/heart attack or have high cholesterol/triglycerides you could cause damage to yourself trying to gain weight in such a short period of time. That being said, I know if I went out and ate whatever I wanted for a week I could easily gain the weight I've worked so hard to lose back in no time.

It's difficult to say what I'd do, especially since statistically you WILL qualify sooner or later, so why not now? But, those guidelines are in place because of safety issues - the larger you are, the better the chance of dying from obesity than surgery.

Share this post


Link to post
Share on other sites
I have three questions, hoping someone can help me..

1) Insurance says they will pay for if "medically neccessary" what does that mean? Does it mean that if I'm at BMI 40 that's medically necc.?

2) I am right at BMI 39-40, I have read people say to start the supervised 6mo diet right away just incase insurance changes thier mind about it down the line, I am worried that the insurance is going to want me to go on the 6 month diet and by then (if I follow it :) ) that I will go under the BMI that's allowed by the insurance co. Do they go by your weight when you first go in?

3) Has anyone try to gain weight to make sure theyre at BMI 40 or above??

AGAIN, THANKS FOR YOUR HELP!!

Kelly,

Do you have documentation of other diets you have tried in the past? I appealed my denial to see a surgeon because I hadn't done a 6 month program. I supplied numerous Weight Watchers records and personal diary entries along with a copy of the National Institutes of Health 1991 Consensus on Bariatric Surgery which does not recommend a 6 month program in its guidlines for surgery.

I won the appeal and did not have to do a 6 month program.

You might also check with your insurance company, some of them have recently changed and are requiring proof of a BMI 40 or over for the past 2 years, so gaining to qualify might not work.

My take on gaining a few pounds...if an obese person relaxed their vigilance over their diet, they will gain enough to qualify sooner or later. The poster asked about 1 BMI point, 6 pounds. The difference between seeing the doctor in the morning or afternoon, or in jeans vs. shorts. We are not talking gorging oneself for a month or two to pack on 30 pounds.

Denise

Share this post


Link to post
Share on other sites
umm maybe you didnt understand what I wrote jersey. Put yourself in that particular situation that I explained. I really doubt anyone can say they wouldnt try to gain a few pounds. Come on, its a matter of not taking a poop before you go to Drs.! As far as the insurance co., (just from reading posts here) they lay out all the guidelines, then you go in for the approval they may or maynot change their minds, may or may not require more info, may or maynot accept your beginning weight. #%$? fight fire with fire!

Ummmm ok. Contact your insurance. None of really truly know if we are qualified for the surgery until everything is submitted. Your surgeons office would know this best, as I am sure they have dealt with the particular insurance company before.

I still don't agree with gaining weight. Thankfully I live in a country where I am entitled to differing opinions.

Share this post


Link to post
Share on other sites

I say do what you need to do.

Insurance companies have no interest in you as a person. They're a corporation that is paying for the surgery because it saves them money in the long run. They've come up with a number (BMI = 40) that creates an easy cutoff for them to go by. When you're dealing with thousands of applicants, that's what you do. My surgeon and office are under the impression that they could care less what your medical history is (unless it involves one of the specifically identified co-morbidities), you HAVE to be above 40. And yes, if the patient loses too much weight, the insurance company can consider that a "successful weight loss attempt" and can deny you coverage for it.

I don't trust insurance companies at all and I say do what you need to do. Anyone who's overweight risks diabetes, strokes, heart attacks, and dying early. The insurance companies don't care about us. They care about maximizing profit. If you feel morally wrong about it, that's fine. But also remember that they don't even CONSIDER helping a person that is anything short of "Obese Class III". They're skipping over "Overweight", "Obese Class I" and "Obese Class II".

Did you know that when people get liver transplants, some insurance companies make them pay any follow up visits or surgical procedures due to complications out of pocket because they consider the original surgery a "pre-existing condition"?

Share this post


Link to post
Share on other sites

One more time. Health insurance is like CAR insurance, you get what you buy. If you buy the one with $5.00 prescriptions, then you get $5.00 prescriptions, not stuff for free. Some policies cover post-op visits, others don't, some cover rehab and home health, others don't. It's insurance, read your policy. And I think intentionally gaining weight is unseemly. But, if you need the surgical intervention, then you should have it.

Share this post


Link to post
Share on other sites

I think what's so controversial about this, is that unless this has happened to you, you just dont know what it's like, and in no way am i saying no one here knows what it's like to be overweight, otherwise we wouldnt be here, and we all know what it's like to be denied things because we are too obese, but can you imagine being denied something because your BARELY not obese enough? What do you do then? It sucks, let me tell you, im too fat to do every other thing in life, but the one thing that can solve all that, and some person whose never met me is telling me im NOT fat enough?

Thats what people mean when they say "put yourself in my shoes".

We arent talking about a 50 lb weight gain here people, we're talking 5-10, maybe 15 lbs MAX to just qualify for a surgery, that can take off 10 times that amt.! Sure, it's not the healthiest idea, obviously, but what else can you really do? You guys say it's cheating the system and finding a way around it, but essentially, that IS what the system is doing to us! Finding any miniscule reason to not pay for the surgery, and most importantly, cheating us out of a chance at life!

But i can understand why people would think it was unethical, but honestly, i mean, 10 lbs isn't going to change your life, but that surgery will, and i think short term sacrifice, is definetly worth what you'll get in the long run.

Agree to Disagree?

I_Will_Survive likes this

Share this post


Link to post
Share on other sites

Create an account or sign in to comment

You need to be a member in order to leave a comment

Create an account

Sign up for a new account in our community. It's easy!


Register a new account

Sign in

Already have an account? Sign in here.


Sign In Now