QUESTION!! Surgery Criteria for Insurance Coverage

jessicakolman · 08-11-2008, 08:09 PM

Hey guys. I plan on attending a seminar next month about the LAP-BAND^® sugery. However I’m just confused on what the qualifications criteria is. I received a packet on the eligibility and it said the following:
1.Must be 100 pounds over ideal weight or have a BMI of 40 or above for 4 of the past 5 years (without co-morbidities) or BMI over 35 for 4 of the past 5 years with documented co-morbidities….ie. hypertension, diabetes, obstructive sleep apnea, etc.
2.Must be able to provide physician documented weight history for the past 5 years. (2004-2007)

So here’s my question.. I DO have a BMI of 41.6 which makes me qualify for the surgery. However it says that I have to have a documented weight history. I know for a fact that I was at a BMI of 35.2 in early 2005. So would that hurt my chances of qualifying?

My other question… “documented co-morbidities” – what exactly does that mean? Does depression count? I went on Realize(tm) Band Candidate Quiz - REALIZEBand.com
And it told me that I was eligible and “I Do have obesity-related health conditions often used to determine surgery qualifications”

So would depression count?? Do I need to be fat longer?? I’m just so confused.. help!

kgranite79 · 08-11-2008, 08:31 PM

Quote:

Originally Posted by jessicakolman

Hey guys. I plan on attending a seminar next month about the LAP-BAND^® sugery. However I’m just confused on what the qualifications criteria is. I received a packet on the eligibility and it said the following:
1.Must be 100 pounds over ideal weight or have a BMI of 40 or above for 4 of the past 5 years (without co-morbidities) or BMI over 35 for 4 of the past 5 years with documented co-morbidities….ie. hypertension, diabetes, obstructive sleep apnea, etc.
2.Must be able to provide physician documented weight history for the past 5 years. (2004-2007)

So here’s my question.. I DO have a BMI of 41.6 which makes me qualify for the surgery. However it says that I have to have a documented weight history. I know for a fact that I was at a BMI of 35.2 in early 2005. So would that hurt my chances of qualifying?

My other question… “documented co-morbidities” – what exactly does that mean? Does depression count? I went on Realize(tm) Band Candidate Quiz - REALIZEBand.com
And it told me that I was eligible and “I Do have obesity-related health conditions often used to determine surgery qualifications”

So would depression count?? Do I need to be fat longer?? I’m just so confused.. help!

Jessica,
There are several things that are considered for insurance approval. It all depends on your insurance company. My BMI is 40.8 and I am 100 lbs overweight with NO co-morbidities. I needed documented weight loss programs but all it was was me filling out the year which program I tried and how much I lost (I got the form from my doctor) I filled it out, had to have a letter written from my primary doctor stating that I am a good candidate for the surgery with several weight loss attempts with no success. I included that along with the sheet with all of my weight loss attempts, completed the required testing and was approved within a week. When I went to the seminar, there was a patient advocate there. I gave her all of my insurance information and before I could even make an appointment to see the surgeon, she called my insurance company to find out if they cover the surgery, if so how much and what the requirements were. Once all of that was taken care of I pretty much knew that I would qualify for it. Luckily my insurance covers the surgery 100% becauae I met all of the requirements. My suggestion to you is, start with the seminar and take one step at a time. You have nothing to lose (but weight lol) do what they ask you to (such as psych evaluation, nutritionist etc) and submit it and cross your fingers. Again this all has to do with which company you have. Certain companies require 6 months on a monitored diet, others don't. But according to you, your 100lbs overweight, and a BMI of 41 sounds like you have all you need (you may not need to have ANY co-morbidities). Co-morbidities are things such as sleep apnea, diabetes, high blood pressure, high cholesterol. Things like that. I am scheduled for my surgery on the 20th, I am on an all liquid diet right now for the 12 days prior to surgery, and let me tell you it sucks. I know it will be worth it in the end! GOOD LUCK and POSITIVE THOUGHTS!!! I HOPE THIS HELPED A LITTLE

afw · 08-12-2008, 11:24 AM

Having one weight in the past five years below the 40 BMI won't hurt you. I wasn't able to show a 40+ BMI every year either. But I had it in 2003, then was exactly a 40 in 2004, then was below it in 2005, then was above it again in '06 and '07. I was approved in 48 hours by Blue Cross of NC, and I also have no comorbidities.

Also, if you have multiple documented weights for a single year, they'll usually use the highest one. In 2003 and 2007 I had additional weights documented that were below a 40, but they used the highest number.

This stuff is confusing, isn't it! Also, you may want to make sure your employer hasn't excluded WLS from your policy. Even if your insurer offers it, your employer may have decided they do not want to pay to cover it.