When does Insurance look at BMI?

kjl315 · 12-01-2007, 05:13 PM

I currently have a BMI of 41, so I fit the guidelines for WLS. Aetna requires me to spend 3 months jumping thru hoops, including doctor supervised diet and exercise. Do insurance companies base approval on the BMI at the beginning of the diet/exercise or at the end? If my BMI drops below 40 by the end of the 3 months, will they then say I don't qualify because I followed all their instructions.

Anyone have any experience with this?

Karen

destiny79 · 12-01-2007, 07:46 PM

they want to make sure that regular diet don't work for u so don't loss much weight

Freebird · 12-01-2007, 08:38 PM

If you drop to, say, 39 BMI, ask your doctor to use your highest BMI for the insurance paperwork. That is what my doctor used for me. And, be glad you only have to jump through 3 months of hoops, with Cigna, it is 6 months of hoops and some insurances are longer than that. I wish you the very best.

**Alexandra** · 12-01-2007, 08:40 PM

The BMI calculation matters when the doctor first submits his request for precertification. I believe--though you should actually ask Aetna about this--that even if you lose enough weight on the three- or six-month supervised diet to drop your BMI below 40 that would be seen as proof you can be compliant, not evidence that you don't need surgery anymore.

kjl315 · 12-01-2007, 08:46 PM

Thanks for the responses. I just worry too much. :nervous

chinatrain99 · 12-04-2007, 02:14 PM

I have a bmi of 60 and can't qualify for LB because I need a BMI under 50. Got my symphathy on this one. I hope your pre-op diet is successful!

betrthnever · 12-04-2007, 02:49 PM

I have a BMI of 40 and my Dr (who is affiliated with the bariatric center) told me that I can't afford to lose more than 5 pounds. I'm 9 weeks into a 26 week (6 month) Dr supervised wl for BCBS of AZ. I also can't gain 5 pounds, either. And I've heard so much conflicting advice in this realm, even within the clinic itself (the Drs can't even agree about the ending bmi!) so I'm playing it safe and not gaining or losing. Its hard and its driving me CRAZY!!!! I'm doing things that I thought I never would just to try to maintain. Keeping my eyes on the prize!

TAH77 · 12-04-2007, 03:13 PM

A representative with Cigna informed me that if you drop below a BMI of 40, then they would not cover the surgery because you would not qualify. Is this the truth? Who knows! I'm right at 41 and with 6 months of diet and exercise could probably drop below 40. That being said, I'm conflicted with the diet thing. On one hand, I know I could take some weight off and feel guilty if I don't try. On the other hand, I've been overweight most of my life, despite sports and exercise, so my history of keeping the weight off is poor. I feel like the Lap Band is what I need for the long haul.

hajohnson1 · 12-04-2007, 03:47 PM

Do you have any other health issues like diabetes or sleep apnea? My insurance company (Blue Cross) will cover the surgery with a BMI as low as 35 if you have related heath issues like those. Try looking into that aspect and see what they say. There should be an entire list of related health issues that they take into consideration.

Good Luck!

Freebird · 12-04-2007, 04:10 PM

TAH77 - - First of all, EACH and EVERY TIME you call Cigna you will get a different answer. The best thing, go into Cigna.com into your account and find the qualifications required by Cigna for your particular policy, it will outline it in detail. (I printed mine out and took it to the physician so they knew what I needed). Our Cigna policy required a BMI of 35 and higher with co-morbidities (sleep apnea, high cholesterol, depression) or a BMI of 40 or higher, a psychiatric evaluation, and MONTHLY visits to the physician with detailed documentation. Do not miss a month's visit or you will have to start all over.

On my six months required diet, I lost a total of 2 pounds, between the ups and the downs and my BMI was at 40 with co-morbidities. It took Cigna 13 business days to approve me , which took in reality, less than 15 minutes. The person that was helping me was on the telephone with the nurse at Cigna while she looked at my paperwork, once they found it after being misplaced, and the process took less than 15 minutes total time.

With Cigna, you have to call, call, and call again. Within one hour's time and 3 phone calls I was told I was denied, I was approved and it was still in review. That's when I called for a fourth time an BEGGED to get a hold of a supervisor and she finally assisted me and by the end of Friday November 30, 2007 I had my approval and am scheduled for surgery on December 17, 2007.

I wish you the very best. Hang in there and don't give up.

TAH77 · 12-04-2007, 04:22 PM

Freebird-- Thanks for the information. From reading a lot of these posts, I gathered that you don't always get the truth from Cigna. In my case, I could lose around 15-20 pounds in the next 6 months and still qualify for the surgery. Although I do have hypertension as well, so I'm guessing I'd still qualify if I slipped below 40. I'm just trying to error on the side of caution I guess and make sure that I'm eligible.

kjl315 · 12-04-2007, 05:24 PM

I had my first consult with the surgeon today and he said they submit my beginning BMI to Aetna, so it won't be a problem. In addition he's sending me for a sleep study because I'm certain I have sleep apnea. Once that's confirmed I can be confident they won't turn me down due to BMI because with that comorbidity I'd qualify down to 35.

Now I can just concentrate on the diet and excercise and start getting rid of this *@$! fat for the last time.

:p

suecasb · 12-22-2007, 12:55 AM

Quote:

Originally Posted by kjl315

I had my first consult with the surgeon today and he said they submit my beginning BMI to Aetna, so it won't be a problem. In addition he's sending me for a sleep study because I'm certain I have sleep apnea. Once that's confirmed I can be confident they won't turn me down due to BMI because with that comorbidity I'd qualify down to 35.

Now I can just concentrate on the diet and excercise and start getting rid of this *@$! fat for the last time.

:p

I have a BMI of 37 with hypertension,sleep apnea and high cholesterol and was just turned down by BCBS today because....my sleep apnea is not severe enough and my hypertension is controlled by meds. I think they want me to have a stroke and then they MAY approve the Lap Band for me!

Anyone know how to write a good letter of appeal?