Susanvmallory

Someone Please read this insurance info and help me

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I was able to get this from a chat online with the insurance company

Here is what you need: Gastric bypass and gastric restrictive procedures with a Roux-en-Y procedure up to 150 cm, laparoscopic adjustable gastric banding (for example, the Lap-Band® System or the REALIZE™ Adjustable Gastric Band), vertical banded gastroplasty, biliopancreatic bypass with duodenal switch, and sleeve gastrectomy (open or laparoscopic) are considered medically necessary for the treatment of clinically severe obesity for selected adults (18 years and older) who meet ALL the following criteria (A, B, and C): BMI of 40 or greater, or BMI of 35 or greater with an obesity-related co-morbid condition including, but not limited to: diabetes mellitus; or cardiovascular disease; or hypertension; or life threatening cardio-pulmonary problems, (for example, severe obstructive sleep apnea, Pickwickian syndrome, obesity related cardiomyopathy); and The individual must have serially documented active participation in a non-surgical weight reduction regimen for at least 6 continuous months, in the 2 years prior to surgery, to enable both behavioral changes and adequate assessment of anticipated postoperative dietary maintenance. These efforts must be fully appraised and documented by the physician requesting authorization for surgery; and The physician requesting authorization for the surgery must provide documentation of ALL of the following (1 through 7): The individual's psychiatric profile is such that the candidate is able to understand, tolerate and comply with all phases of care and is committed to long-term follow-up requirements; and The candidate's post-operative expectations have been addressed; and The individual has undergone a preoperative medical consultation and is felt to be an acceptable surgical candidate; and The individual has undergone a preoperative mental health assessment and is felt to be an acceptable candidate; and The individual has received a thorough explanation of the risks, benefits, and uncertainties of the procedure; and The candidate's treatment plan includes pre- and post-operative dietary evaluations and nutritional counseling; and The candidate's treatment plan includes counseling regarding exercise, psychological issues and the availability of supportive resources when needed.

So is this saying I could be approved with a  BMI of 35-39.9 with only 1 comorbidity?

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6 minutes ago, Susanvmallory said:

I was able to get this from a chat online with the insurance company

Here is what you need: Gastric bypass and gastric restrictive procedures with a Roux-en-Y procedure up to 150 cm, laparoscopic adjustable gastric banding (for example,

BMI of 40 or greater, or BMI of 35 or greater with an obesity-related co-morbid condition including, but not limited to: diabetes mellitus; or cardiovascular disease; or hypertension; or life threatening cardio-pulmonary problems, (for example, severe obstructive sleep apnea, Pickwickian syndrome, obesity related cardiomyopathy); and ............

So is this saying I could be approved with a  BMI of 35-39.9 with only 1 comorbidity?

That's what it tells me Susan.

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Just now, cinwa said:

That's what it tells me Susan.

Oh thank goodness I am having a sleep study soon and scheduled my sleep conso for the 11th. I snore like a wilder beast and wake myself up I am sadly praying I have severe sleep apnea. I also would wear a cpap because I never feel rested.

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2 hours ago, Susanvmallory said:

Oh thank goodness I am having a sleep study soon and scheduled my sleep conso for the 11th. I snore like a wilder beast and wake myself up I am sadly praying I have severe sleep apnea. I also would wear a cpap because I never feel rested.

Even though I posted in your other thread about the BCBS requirements, if you seriously can't get a straight answer from someone, then just push on with the approval process- go to the seminar, fill out the forms etc. You will probably find out pretty quickly if you're eligible or not, although I'd keep my heart neutral while I was doing it :-)

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Awesome news Susan!  You just need one!  It may sound really strange but hoping for sleep apnea! <3  I'm sure you have it though.

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@Susanvmallory

Reads that way to me,  with a BMI > 35 but below 40, 1 co-morbid condition + 6 months or more of supervised attempt to lose weight in the past 2 years.

Be sure you understand the "supervised attempt" to lose weight stuff closely... @michiganmilkman (Rob) gained a couple of pounds over 6 months and was initially denied - - - never knowing he had to have lost something. He won on appeal and is having his surgery in a month or so. 

I'd still email them and confirm the chat discussion. 

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It looks like you need just one. Edema is an easy comorbidity to diagnose. If your socks leave dents in your legs for awhile after you take them off, you have edema. Edema is caused by poor circulation due to your size and is very common. If this is something that pertains to you, you need to get it documented by a DR and voila you have a comorbidity. The more comorbidities you can get listed the more likely you will get approval.

Edited by AustinJ

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10 hours ago, Susanvmallory said:

Oh thank goodness I am having a sleep study soon and scheduled my sleep conso for the 11th. I snore like a wilder beast and wake myself up I am sadly praying I have severe sleep apnea. I also would wear a cpap because I never feel rested.

The cpap will help you out tremendously. I walked around like a zombie I was so exhausted before I was diagnosed years ago. Either way you can't go wrong having the sleep study.

I posted a link in one of your threads yesterday showing that you only needed one comorbidity with BMI of 35. Pretty sure that @athenarose said that she has same insurance and you actually need two.

Your insurance rep at bariatric center will help you get it sorted. I thought that they had already told you that you need two with BMI of 35. I may be confused though. Too many threads and not enough time lol

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@ReadytobemeYeah when I called yesterday to the weight loss center I messed up and said I had BCBC of CA so they told me if my BMI was not over 40 or at 40 i had to have  two comorbidities but I it’s actually anthem Blue Cross Blue Shield PPO of California so today through the I surqnc chat I was able to Get the proper information and as it stands I have two options. A my BMI has to be 40 or B a BMI of 35 to 39.9 Iand only one comorbidity. So currently my BMI is 36.9 however my doctors office has my height as 5  foot 8 1/2  also as 5 foot 9 in another visit. If I am only 5 foot 8  I could technically qualify at 263 pounds with no comorbities So in the unlikely event that I do not have sleep apnea I have just resolved to the fact that I am not going to try to lose weight anymore and I will most definitely gain weight. I have such large fluctuations in my water weight and  I can literally be 10 pounds heavier at any given day if I eat foods high in sodium. 

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1 hour ago, Susanvmallory said:

@ReadytobemeYeah when I called yesterday to the weight loss center I messed up and said I had BCBC of CA so they told me if my BMI was not over 40 or at 40 i had to have  two comorbidities but I it’s actually anthem Blue Cross Blue Shield PPO of California so today through the I surqnc chat I was able to Get the proper information and as it stands I have two options. A my BMI has to be 40 or B a BMI of 35 to 39.9 Iand only one comorbidity. So currently my BMI is 36.9 however my doctors office has my height as 5  foot 8 1/2  also as 5 foot 9 in another visit. If I am only 5 foot 8  I could technically qualify at 263 pounds with no comorbities So in the unlikely event that I do not have sleep apnea I have just resolved to the fact that I am not going to try to lose weight anymore and I will most definitely gain weight. I have such large fluctuations in my water weight and  I can literally be 10 pounds heavier at any given day if I eat foods high in sodium. 

That's great news! There is usually a way if we are persistent enough. Don't give in and don't give up. You will get there.

 

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2 hours ago, Susanvmallory said:

@ReadytobemeYeah when I called yesterday to the weight loss center I messed up and said I had BCBC of CA so they told me if my BMI was not over 40 or at 40 i had to have  two comorbidities but I it’s actually anthem Blue Cross Blue Shield PPO of California so today through the I surqnc chat I was able to Get the proper information and as it stands I have two options. A my BMI has to be 40 or B a BMI of 35 to 39.9 Iand only one comorbidity. So currently my BMI is 36.9 however my doctors office has my height as 5  foot 8 1/2  also as 5 foot 9 in another visit. If I am only 5 foot 8  I could technically qualify at 263 pounds with no comorbities So in the unlikely event that I do not have sleep apnea I have just resolved to the fact that I am not going to try to lose weight anymore and I will most definitely gain weight. I have such large fluctuations in my water weight and  I can literally be 10 pounds heavier at any given day if I eat foods high in sodium. 

I had Anthem BCBS CA too. I didn’t realize there’s a different kind of insurance with such a similar name. I was kind of confused when you initially posted the thing about the two comorbidities because I thought it was only one, but 1) I didn’t have any comorbidities so I didn’t pay super close attention to that requirement when I went through the process and 2) it’s been two years and things can change. But all that said, it sounds like, assuming you have sleep apnea, you’ll qualify for WLS as you are, so yay! And if you don’t, you have a solid back up plan. I hope it all works out for you and the rest of the process goes smoothly.

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