Susanvmallory

Very discouraged with Insurance

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Spoke to my weight loss surgery center a few minutes ago, they are very familiar with my insurance and unfortunately my BMI is not 40 and though It is over 35 I do not qualify because I do not have any of the  two comorbidities that Anthem BCBC PPO of CA would require!! So my 8 year weight struggle will continue...very upset feel like I could cry!! I am 5 foot 9 and as of this morning weigh 248 lbs. Guess I have to wait until I develop a few life threatening diseases or save up and pay cash. Feeling defeated today.....:(

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1 hour ago, Susanvmallory said:

Spoke to my weight loss surgery center a few minutes ago, they are very familiar with my insurance and unfortunately my BMI is not 40 and though It is over 35 I do not qualify because I do not have any of the  two comorbidities that Anthem BCBC PPO of CA would require!! So my 8 year weight struggle will continue...very upset feel like I could cry!! I am 5 foot 9 and as of this morning weigh 248 lbs. Guess I have to wait until I develop a few life threatening diseases or save up and pay cash. Feeling defeated today.....:(

Once I had decided I wanted WLS, it took me two years to finally get it, due to various insurance obstacles.  I know very well what you're feeling right now, it's a letdown.

It looks like you'd have to weight at least 271 to have a BMI of 40.

I did seriously consider, and research having my procedure done in Mexico. There are many excellent facilities there and it is substantially cheaper if you're paying out of pocket. Several of our very successful members here on the forum had their procedures in Mexico, I do hope they give you their perspective.

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So annoying but I cannot change these insurance required stipulations!  I guess for now I’ll make certain to get my sleep study done and wait for either another chronic life threatening disease or gain weight! 

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*Hugs*

Susan, I too was under the 40% threshold, but had a sleep study done and I DID have sleep apnea.  I had no idea I even had it.  Do you need just one pre-existing condition?  My best advice is schedule the sleep study asap.  Insurance regulations are truly annoying and make no sense to me.

Edited by TammyP
addition

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I need two so I’m going to have the sleep study done and maybe with some luck that will work but it has to be severe sleep apnea. The insurance website is so confusing but the surgeon seems to think I need two comorbidities not one. Maybe I should call the insurance ?

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8 minutes ago, Susanvmallory said:

I need two so I’m going to have the sleep study done and maybe with some luck that will work but it has to be severe sleep apnea. The insurance website is so confusing but the surgeon seems to think I need two comorbidities not one. Maybe I should call the insurance ?

it wouldn't hurt to call them.  Is your cholesterol elevated?   Check w/ the ins co to see what else is required in order to be eligible.  My aunt had the same problem and actually ate her way from Thanksgiving  to New Years THEN she qualified!  How silly to make her do that in order to get the surgery (tho it actually sounded fun at the time...tho totally unhealthy!).

So, yes have the sleep study done, that might qualify you (i had "mild" sleep apnea which helps get you qualified)

Also, it sounds funny but get remeasured...I didn't qualify at 5'5" but I said "I am not that tall!" so they remeasured me and 5'4" was ok!  (so take your shoes off, and fill your pockets w/ bricks and you might make it!) 

 

Edited by CheeringCJ

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5 minutes ago, Susanvmallory said:

I need two so I’m going to have the sleep study done and maybe with some luck that will work but it has to be severe sleep apnea. The insurance website is so confusing but the surgeon seems to think I need two comorbidities not one. Maybe I should call the insurance ?

Definitely call insurance and get the info straight from them. But, at the end of the day, you may just need to gain weight in order to qualify for surgery. I know it seems counterproductive, but if gaining weight can qualify you, it may be the best option. I was in a similar boat, but I didn’t have any co-morbidities. So I chose to gain the weight so I could qualify and, in the long run, it was the best thing I could’ve done. I hope it all works out for you. 

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Just keep in mind, some insurance companies require a 2-3 years of documented weight (mine did). 

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1 hour ago, TammyP said:

Just keep in mind, some insurance companies require a 2-3 years of documented weight (mine did). 

BCBS CA PPO doesn’t require that (or at least didn’t when I went through the approval process/had my surgery). In fact, we were worried that they might not accept my medically supervised diet because it was 18-24 months old (they did, without issue. My surgery was approved less than 24 hours after they submitted it). And, again, even my highest weight during my supervised diet would not have qualified for me for surgery. None of that mattered to BCBS CA PPO (in my experience, at least).  But it’s good to be aware. 

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@athenarose so basically you needed to gain some weight for the initial weight submission to qualify you but after this you were fine?  

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1 hour ago, Susanvmallory said:

@athenarose so basically you needed to gain some weight for the initial weight submission to qualify you but after this you were fine?  

No. I did things sort of backwards because I had done a doctor supervised diet over a year before I even looked into WLS (and we submitted that for my 6 month supervised diet crossing our fingers that BCBS would accept it as fulfilling that requirement, which they did).  But once I went to my surgeon, they were very insistent that I not go below a 40 BMI until after insurance approved me for surgery. The message I got was that not only does your initial weight submission need to qualify you for surgery, but your weight at the time that they submit the request needs to still qualify you for surgery. Does that makes sense? But the fact that my weight was a lower BMI  prior to my initial consultation with my surgeon didn’t matter to them at all.

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I have BCBS TX.  The differences even amongst BCBS is interesting.  I would call your insurance company @Susanvmallory.

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@TammyPdid you have to have two comorbidities if your BMI was under 40 because I am ready to just let the weight take over and qualify with my BMI. I have literally been struggling with my weight for over eight years and 23 pounds is going to prevent me from having a life changing necessary surgery it is so ridiculous to me. I’m a nurse I know the health risk involved eventually I will have life-threatening illnesses and eventually my BMI will be well above 40 if I continue on this path it is sickening to me.... all the hoops the insurance company requires you to jump through when you’re asking for help. 

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56 minutes ago, Susanvmallory said:

@TammyPdid you have to have two comorbidities if your BMI was under 40 because I am ready to just let the weight take over and qualify with my BMI. I have literally been struggling with my weight for over eight years and 23 pounds is going to prevent me from having a life changing necessary surgery it is so ridiculous to me. I’m a nurse I know the health risk involved eventually I will have life-threatening illnesses and eventually my BMI will be well above 40 if I continue on this path it is sickening to me.... all the hoops the insurance company requires you to jump through when you’re asking for help. 

- Get the sleep study done, maybe you don't need to gain the 23 lbs. How about arthritis? I had hip and knee arthritis, sleep apnea and a bad back, that is what got me okayed. Fatty liver? I doubt any of us going for surgery don't have a fatty liver. I did. GERD? That can be a complication of obesity too. Your insurance carrier should have  a list of the acceptable comorbidities they will accept ...

- Be sure to have your height measured at the end of the day when you've been on your feet and your vertebral column is the most compressed and you have bare feet. That should help boost your BMI. Slouch when measured too.

No comment from me about the insurance companies, since I have a dainty personality and the words that come to mind are banned from the site.  This is totally stupid and counterproductive.

The angry side of me says, Of course you could call their corporate lawyer's office, tell them your best friend at the Courier-Journal is really interested in  your having to gain weight to qualify for the surgery that will help you to lose the weight and more.  You could enlist us to write letters to your insurance company saying we will be happy to publicize their thinking and to add our personal thinking to this. 

Edited by BurgundyBoy
Not finished

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43 minutes ago, BurgundyBoy said:

- Get the sleep study done, maybe you don't need to gain the 23 lbs. How about arthritis? I had hip and knee arthritis, sleep apnea and a bad back, that is what got me okayed. Fatty liver? I doubt any of us going for surgery don't have a fatty liver. I did. GERD? That can be a complication of obesity too. Your insurance carrier should have  a list of the acceptable comorbidities they will accept ...

- Be sure to have your height measured at the end of the day when you've been on your feet and your vertebral column is the most compressed and you have bare feet. That should help boost your BMI. Slouch when measured too.

 

When I had my height/weight measure for orthopedic surgery I didn't know that while the weight was being taken a laser was taking my height measurement. Looking down at the scale reading took almost 10cm (4 inches) off my height. While for WLS purposes I would expect them to tell you to stand up straight, in the case of borderline BMIs they might well allow a good slouch with no shoes when taking height.

I'm seconding those that suggest making a head start on your health checks. You'll be required to have so many prior to surgery that could well expose further co-morbidities that you're currently unaware of. You only need one more with your sleep aponea. I know so many people that once they were diagnosed with sleep aponea went on to develop other comorbidities.

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2 hours ago, Susanvmallory said:

did you have to have two comorbidities if your BMI was under 4

Susan - I only had to have one comorbidity with BCBS TX.  Your insurance company should be able to give you more info, and even the documentation on their requirements if you request it.  

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@TammyP I called them and as you can see by my other post they were the most unhelpful people in the world and told me that I would have to be seen by bariatric surgery center of excellence and they were the ones who make the decisions and I know well and clear they have a set of specific provisions to cover weight-loss surgery depending on BMI and comorbidities they will not tell me if I have to have one or two comorbidities and what comorbidities they except I cannot find the information anywhere. So frustrating I will gladly give anyone the phone number to call to see how incompetent these people are and how they cannot answer a direct question and  give me the information I am requesting. 

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3 hours ago, Susanvmallory said:

they were the most unhelpful people in the world

Sorry you are dealing with idiots @Susanvmallory.  I can kind of let you know how things worked for me.  The first thing I did was visit my PCP for my annual female/wellness visit.  At my request, she then referred me to a bariatric surgeon in my network that she very highly recommended.  I met with Dr. Davis, who told me I was borderline since I was right at 35% BMI.  Then I went directly to his nurse, who verbally ran through all of the requirements pre-surgery, and we discussed the need for one pre-existing condition (most likely).  Then the bariatric office contacted BCBS TX to verify their requirements.  I did not have hypertension or diabetes, so the sleep apnea route sounded like the first thing to explore.

All this to say, your liason with your insurance company should be your doctor/Bariatric facility in my opinion.  Your insurance company WILL have to talk to them, unlike their being belligerent with you.  BCBS TX was very open to talking with me, but in your situation I would have the Bariatric Clinic sort this out.  The clinic will want to know because they will want to get paid.  Hang in there hun! 

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4 hours ago, Susanvmallory said:

they will not tell me if I have to have one or two comorbidities and what comorbidities

It's pretty standard for insurance requirements- at least 40 BMI, or 35 BMI with two comorbidities. 

Looks like Anthem BCBS is no different- https://www.obesitycoverage.com/anthem-bcbs-requirements-for-weight-loss-surgery/

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On 2/20/2018 at 8:20 AM, Susanvmallory said:

Spoke to my weight loss surgery center a few minutes ago, they are very familiar with my insurance and unfortunately my BMI is not 40 and though It is over 35 I do not qualify because I do not have any of the  two comorbidities that Anthem BCBC PPO of CA would require!! So my 8 year weight struggle will continue...very upset feel like I could cry!! I am 5 foot 9 and as of this morning weigh 248 lbs. Guess I have to wait until I develop a few life threatening diseases or save up and pay cash. Feeling defeated today.....:(

I have/had Medica insurance a subsidiary of BCBS and they told me they do not cover WLS. So I looked into state laws. In Iowa WLS is considered a "Medically necessary procedure" and is required to be covered if your PCP of Surgeon deem it necessary to prevent future medical issues. So I was able to use a family history of diabetes and heart disease as my 2 comorbidities.

There are a few things like edema, mobility issues, joint pain, and back pain that one DR will not see as an issue and other DR's will say are a sign of life threatening issues.

Just be persistent, the insurance company doesn't want to pay for anything it doesn't have to. Sometimes you just have to push them into a corner.

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@Susanvmallory

I think @AustinJ is on to something important here: family history of diabetes and heart disease.

That is on the list of "possibly qualifying" conditions I was able to find with just simple googling yesterday when I read your initial post in this thread. 

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I agree with @TammyP; you should let the Bariatric Center go to bat for you. I know mine has an insurance specialist who contacts each plan to help the patient figure out exactly what they need to do.  If you're just calling customer service you will probably never get a resolution; there is a really high turnover rate in those positions and you often can get 5 different answers from 5 different people.  Or if your employer is a large one, they may have someone who can help you sort it out, if you're comfortable with getting HR involved.  I wouldn't have been...one of the most gossipy people I know works at our HR lol.

Be persistent; the answers are out there it's just a matter of figuring out where.  You are worth it!

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This is the link to Susan's latest thread giving insurance information.  It would appear that they require a BMI of 40 or greater, or BMI of 35 or greater with an obesity-related co-morbid condition  ...

 

 

 

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