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Disapproved for purposely gaining weight to qualify?

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Hi all, I'm new here. I've already gotten lots of useful stuff from this forum, it's a great resource!

Anyway, has anybody been disapproved by BCBS (federal employee) because their record showed that they gained weight to qualify?

Last fall (October 2nd 2009), I was 16 pounds under 40 BMI (no comorbidities). The surgeon said to come back again next year. Needless to say, the holidays did the job and I didn't have to gain "on purpose". My fibromyalgia and arthritis pain also "helped" to keep me somewhat inactive.

Now I am only 2 pounds under BMI, and will be weighed in 2 weeks. My nutritionist and I am confident that I will make the 40 BMI. Naturally, all of these weights are recorded in my file.

However, the insurance person seems to think I'll be disqualified for a 16-pound gain because it looks like it's on purpose.

We all know that just wearing different clothes or having your period can make your weight different. Splitting hairs!!

Anybody else have a similar experience, and what was the result?

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i cant say im in your position, but my 2 cents is that they cant just deny you because you've gained weight...I've gained weight through this process, and not on purpose either, but it is a stressful process and the holidays did do quite the number...lol, but if i were you, i wouldn't worry... i think as long as your PCM and Nutritionist don't think you gained on purpose, then you should be good...but im sure the insurance cant deny you for speculation ...but i could be wrong, lol thats just my opinion.

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I can't comment on the issue of gaining weight excluding you from surgery but I would like to point out that it's proven that WLS can significantly improve the debilitating effects of fibromyalgia.

The effect of laparoscopic Roux-en-Y gastric bypass on fibromyalgia.

Saber AA, Boros MJ, Mancl T, Elgamal MH, Song S, Wisadrattanapong T.

Department of Surgery, Michigan State University/Kalamazoo Center for Medical Studies, 1000 Oakland Drive, Kalamazoo, MI 49008, USA. saber@kcms.msu.edu

BACKGROUND: Fibromyalgia is a chronic debilitating disorder affecting 3-5% of the US population. Treatment of this disorder is a challenge. The incidental finding of improvement of fibromyalgia following laparoscopic Roux-en-Y gastric bypass stimulated us to study this phenomenon. METHODS: A retrospective chart review of patients with fibromyalgia who underwent laparoscopic Roux-en-Y gastric bypass. RESULTS: Postoperative decrease in median of BMI from 49.4 to 29.7 was significant (p value = 0.0010). This was associated with statistically significant improvement in median of pain score (p value = 0.0010) and median points of tenderness (p value = 0.0010). CONCLUSION: Significant weight loss following laparoscopic Roux-en-Y gastric bypass is associated with resolution or improvement of fibromyalgia. Consequently, the bariatric surgeon should be a member of the multidisciplinary team approach for treating fibromyalgia.

A BMI of 40 is normally the criteria for WLS, BMI of 35 with comorbidities.

Given the above, you need to check whether BCBS accept fibromyalgia as a comorbidity.

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Thank you both! Thanks for the WLS/fibromyalgia info. I knew that significant weight loss helps it quite a bit.

BCBS doesn't consider fibromyalgia a comorbidity. But, that is one of the main reasons I decided to do this. Both my fibromyalgia and my arthritis are making my working life very difficult, and I have to do something.

The insurance lady was negative and kind of pissy. Maybe she's got PMS today, I'll give her the benefit of the doubt. She's the first non-supportive influence so far. My nutritionist is awesome, though.

My surgeon said to come back this year, and that's what I'm doing. One more visit with the Psych and Nutritionist (with the qualifying weigh-in), and I'm ready.

Thanks!

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I "sort of" gained weight to qualify and was approved. My story is that I have gained and lost TONS of weight over the years (so it was documented in my medical history that my weight had been way above qualifying at several points in my life). The last straw for me was when I lost a lot of weight through Opti fast. Once I went off the program I had to fight constantly to try to keep the weight off - and it was creeping back on anyway. So...I decided to quit fighting to keep it off - let it come back - it was going to sooner or later anyway (always had). When I reached a level where I would qualify I started the process.

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I don't think you need to worry. Like someone already said, I find it hard to imagine they could deny you on mere speculation. Personally, I have BCBS federal basic. I did gain 8lbs to qualify; but my insurance did not require any kind of weight history and they only care that I have a 40 bmi NOW. My sx is April 26. The hardest part for me was getting my surgeons office to actually submit my stuff. Took them a whole month and then I was approved the same day. Think positive!

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Thanks tbott! I have BCBS federal basic also.

I can't believe how hard it is to gain weight at this point - arghhh. This is ridiculous.

I'm thinking the insurance woman at my surgeon's office was crabby. She really put me on a downer!

I'm going to be bugging them to get my case in quickly. I've seen a few others that were approved in a day by BCBS federal too.

Thanks for the encouragement, everyone! Maybe I'll sleep better tonight...

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Hi Im new to here and just enrolled to have the surgery and at my info session I was told that they had several that had been denied due to weight gain. So they warned us against it....just an FYI that i had at least heard of it being done not that it is your case honey....Im a BCBS (federal) as well! So nice to meet you! And good luck on your journey:)

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I purposely gained 20 lbs to qualify back in 2006 when I had the band (I didn't have BC/BS). I've since revised to RNY and that wasn't an issue this time around but how in the world can they possibly know you gained it on purpose???? That's ridiculous. I really hope you get approved. Good luck!

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I have two medical insurances. I have Medica with United Healthcare through my work and they cover the surgery. I also have BBCBS of TX thru hubby's work and they cover $0 of surgery. For my insurance I had to gain 10 lbs to qualify. Felt weird that I HAD to gain weight. Good luck and hope you get approved!

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Typically the first level approval process is just someone going through a checklist. In my experience, no one is spending much time looking at your actually medical history unless there is a problem with the "checklist". So basically your options are gain the weight and MAYBE get pinged, or do not complete the "checklist" and DEFINITELY get pinged.

Truthfully you probably could get approval with a BMI under 40 with the fibromyalgia, but only on appeal (which is normally when they take the time to actually evaluate your medical necessity:rolleyes:).

Edited by watfam4

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I gained during the 6 month diet, and it was not on purpose, just screwed up like I've done with many of my past diets. I was just approved for my surgery last week. The co-morbitities, my age, 45, and my family history, diabetes both sides (dad just received a second kidney transplant) trumped the scale numbers. Don't worry it'll work out.:)

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Thank you everyone!

My next question is this: Once I become qualified (hopefully) and am approved and have a surgery date scheduled, what if my weight goes back under 40 BMI during the intervening time? I know it will go way down during the liquid diet.

Is the health insurance contacted again with my weight prior to surgery, and if so, will that disqualify me again?

Boy, when people talk about a long and painful journey, they are not kidding.

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On March 11, 2010 at 10:09 PM, Lana said:

I purposely gained 20 lbs to qualify back in 2006 when I had the band (I didn't have BC/BS). I've since revised to RNY and that wasn't an issue this time around but how in the world can they possibly know you gained it on purpose???? That's ridiculous. I really hope you get approved. Good luck!

How did you get approved for a revision?? I need a revision from sleeve to RNY because of SEVERE acid reflux that is horrible every single night and destroys my sleep! It is so bad that I now have Barrett's Esophagus! I just got over battling breast cancer 3 years ago and I'm afraid if I don't get this done and soon, I will end up having esophagus cancer too!! I am only about 40 pounds overweight so I know that I don't qualify by BMI!! Can you tell me how you got your revision approved?? Also, do you have the Community Plan??

 

 

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7 hours ago, Luvbeamer said:

How did you get approved for a revision?? ....

Lana hasn't been on the forum in 5 years but hopefully others will be able to help.

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Oh thank you! Yes it looks like most people have not posted in years! 

 

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1 hour ago, Luvbeamer said:

Oh thank you! Yes it looks like most people have not posted in years! 

 

That's OK.  You quoted Lana and she hasn't been on the forum in 5 years.  

But you've bumped this old thread back up so hopefully, some of our currently active members may be able to jump in. 

 

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Hi Luvbeamer,

i don't personally have experience with this but I do work in heathcare, for what it's worth. 

Revisions can be sought because of unsatisfactory weight loss with the lap band or sleeve, or because of complications like yours. Barrett's esophagus is plenty serious and should be reason enough to get you approved for revision. You can call your insurance company and ask them what their criteria is. If you have a nurse navigator or case management team available at your insurance company, tap into that. They have more time and they are able to dig deeper than customer service reps to give you complete information. My understanding is Bypass can all but cure reflux for most, and it's cheaper than paying for complications from Barrett's! I wish you lots  of luck! 

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On 28. Juli 2016 at 7:27 AM, Luvbeamer said:

How did you get approved for a revision??

I got revision from GB to bypass because of reflux issues. This isn't about weight loss surgery but about reflux surgery. However, I'm in Germany so insurance policies are for sure different.

Edited by summerset

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