44.6 BMI and insurance says I need to gain more

[Dockman4]

O.K. This is my first post to this wonderful forum...so go easy on me. I was inspired by all of you on this site, so I took the plunge and went to a bariatric seminar. I, like many of you, have tried EVERY diet and finally want to do something once and for all. At the seminar, I was told I was a perfect candidate for the lap band. I've got a BMI of 44.6%, I'm diabetic (type 2), use a CPAP for sleep apnea, high blood pressure, you name it, if it has to do with being obese, I've got it. Their criteria was a BMI of 40% or 35% plus 2 obesity related problems. I easily fit into both catagories. I was going to do the self pay. Things were good.
Before I jump into it and spend $25,000, I decided to see what my insurance company (Kaiser Permanente) had to say as they just built a bariatric weight loss surgery center close by. My doctor, who is awesome, put a referral in for me. He feels that I'm a perfect candidate for bariatric surgery. I got a call from the review board the very same day. I was denied because all of my weight related problems were being controlled by medications and my health is not at risk at this time. However, I was told that if my BMI was 45% I'd be a candidate. Here's where I'm at...I could gain weight (about another 10-15 lbs) and try again (at which time I'm sure they'll come up with some other excuse not to band me), or, I could go the the hospital that I went to the seminar (where they've been doing weight loss surgeries for 15 years) and self pay and get on with my life. My quality of life is really going down and I can't enjoy things that are important to me (camping, hiking, family outdoor activities). Have any of you fine people had this happen to you? Would you gain the weight in hopes of having the insurance company pay? I want to lose weight, not gain more that I'll just have to lose later. Any input is greatly appreciated. And please, feel free to let me know if you think I'm whining. I just want to hear from you. Thanks in advance. Rick
p.s. I can't wait for the day when I have a before and after picture on this forum.:thumb:

[Mloukas143]

Surgery is a risk in itself. All surgeries are dangerous. You are taking several chances by allowing yourself to gain weight. For one thing, the foods you eat to gain weight will be easy for you because like all of us we love food..so gaining weight wouldn't be a problem. Would it teach you anything you need to learn on the road to weight loss? Absolutely not. In fact you would be taking quite a few steps backwards by gaining weight. Also, your insurance company can always deny you so if you did gain weight and were denied then you would be in a really sticky situation. The most important reason why I wouldn't gain weight is for the fact of surgical reasons. You want to be as fit and healthy as possible when going into surgery. Gaining more weight would only put more strain on your heart and other organs in your body...thus increasing the risk of complications during your surgery. Would I pay self pay for the surgery? That depends on your financial state...
I wish you the best of luck. Sometimes I don't understand how insurance companies work. I had a BMI of 40 with no co morbidities and I was approved. Go figure.
Take care, and welcome to B2G

[JayCee]

First of all, welcome to B2G. I have just recently been banded and am still on liquids. If I had to make the decision to self pay or gain weight in hopes that the insurance company might, and I say, might cover the expense? No way. The limits for being banded are supposed to be dropping so your insurance company might cover it if you appeal their decision. I would not gain weight but would appeal their decision. Get your doctor involved and let them write a letter of medical necessity. But lap band is the way to go. Keep us informed of your decision and progress.
Jan

[SixOfOne]

Once upon a time I gained weight to get the bypass. Still got denied. This time I did self pay in Mexico. I'm an RN & was really impressed with the quality of the healthcare I received in Cancun. The surgery was $5400. Your BMI only needs to be 40 with no health problems or 35 with one co-morbidity. I spent about $7000 total and did the band on day 5 of a 9 day trip. Was back on the beach by day 7 (you can sip and shuffle in the sand). Had very little trouble finding a fill doctor when I got back.

[Rini]

yikes! I can't believe they denied first of all. I would try an appeal if you can manage that. Perhaps the doctors office can help you with the necessary paperwork. As for gaining to get the surgery i'm not so sure thats a good idea given all your health issues. You may end up doing more damage than good.

[Dockman4]

You guys are awesome. Thanks for replying to my post. From all the research I've done, you have to lose some weight prior to the surgery, so having to gain some weight to qualify for it sounds alittle counter-productive to me. I will take your advice and NOT gain the weight. I agree, I want to be as healthy as possible for the surgery so I'm going to continue to try to lose while I wait. I'm going to appeal their decision, but I'm pretty skeptical when it comes to insurance companies, so I'm not expecting much from that...but it's worth a shot. I'm not very wealthy, so the self pay is going to hurt alittle, but my wonderful wife understands that I won't be around as long if I don't have the surgery, so she's totally behind me. Again, thanks for the input, and I will definitely keep you posted. Hoping to get banded. Rick

[Mloukas143]

Also, check into a hospital that has a bariatric certifcation of excellence. Apparently insurance companies look highly to these hospitals. If you go to a hospital that has this and will also put you through a 6 month program, you may have some luck. I also sent in a stack full of papers to my insurance company including every receipt from every diet i've bought and attempted, my fluctuations of my weight from my doctor's office, 2 letters of recommendation, photos of my body, print outs of my health problems (which was only high triglycerides) and i also wrote them a letter stating why i felt this surgery would benefit my health and how i would use it to my full potential. just some things to add to your list when sending things into your company.

[Dockman4]

Thank you Melissa. I just got an e-mail from my PCP and he said that he would refer me again in January. My insurance (Kaiser) would be doing the surgery in-house, at their own hospital and I'm not sure if they are certified...my quess is that they're not. The bariatric center that I attended the seminar at is "center of excellence" certified. We'll see what happens then. It sounds like this is the beginning of a very long journey...but then, nothing worth having comes easy, right? I'll keep you all posted. Have a wonderful holiday. Rick

[mamaknows]

Hi Rick. Sorry to hear what you're going through. I have a similar story. Three years ago I wanted to be banded and my ins. required I have, besides the obesity, at least two other issues. I had bad knees (and both needed surgery), HBP and sleep problems. Sounds like plenty, yes? Well I was denied. They said my health problems were not "life threatening". Says who?

So I waited. Tried phen and did fairly well but suffered bad side effects. This year my ins (same one) includes bariatric surgery as a preventitve proceedure.....so if I lose weight, I will cost them less in the long run. Took them long enough to figure out what to the rest of us is a no-brainer.

In any case I jumped on the opportunity and went to seminar, then made appt to meet with surgeon. I planned to go ahead with lap band as originally planned but he told me about vertical gastic sleeve (which was cheaper but insignificant to me since I had paid my deductible for the year on a 90/10 policy). I looked into it and decided to go that way. My total out of pocket was around 3500 which I had, no problem. Ins covered all else.

My point is they finally got with the program. I had to go to the dr. every six to eight weeks for my health problems and was on 5 meds when I had surgery. I am off two (one is my BP med). having the surgery will cost them less in the long run. Hopefully as UHC did, your ins will come around. I would not gain weight though. That seems extreme. Basically they are telling you if you get more "unhealthy" you can have surgery. Doesn't that sound foolish? They should be trying to get you well so you cost them less....duh!

See if your dr will intercede on your behalf and do appeal the decision.

Best of luck. I hope you get the surgery one way or the other. It is SO worth it!
Di :nod:

[Katiegirl]

I have a great idea. Wait a week.. add weights to your shoes, add weights to your pockets, wear heavy layers and drink as much water as you can the day of your appointment and see if you can bump up your weight like that. You don't have to gain (real) weight and you will be able to get help paying for the surgery!!

[Dockman4]

I like that Katiegirl. I'm thinking of walking around with weights on my head so I won't be as tall next time I check in too. Lol. Seriously though, I will suck down a bunch of water prior to going in. You guys are all great...thanks for all the support. Rick

[sweetknee]

I have also heard of people putting rolls of quarters in their pockets !

[nightnurse]

My insurance said you have to have a high BMI and maintain it for 2 years or more. I like kates idea best.

[Neal R.]

That is crazy on the insurance company's part. Most literature and almost everyhting I have heard and read suggests that a BMI of 35 is sufficient for WLS of any type, especially the band.

[Dockman4]

Thanks for all the support folks. Thought I'd give you a quick update. I'm going back in to my PCP tomorrow for a re-weigh and they are going to re-check my height as that will affect my BMI. My PCP is totally on board with me getting the surgery, so he's going to push it as hard as he can. I did gain alittle weight over the holidays, but not enough to qualify. I'll find out more tomorrow or the next day. I'll keep you all posted. Cross your fingers for me...Thanks all. Rick

[Dockman4]

UPDATE: Well I went in yesterday. I drank about 3/4 of a gallon of water prior to going in for my appointment. I also took my shoes off when they measured my height...lost about a 1/2 inch. So now my BMI is officially 46.75 according to my PCP. He was almost as excited as I was. He re-referred me and after 2 days, I still haven't heard anything. That's a good thing, maybe, because they called me back the same day when they denied me. However, I'm afraid their just looking for another reason to deny me. I also found out that they don't offer the lap band as an option. I don't know what to do. They only offer the gastric bypass. I could still go to the other hospital and get the lap band at my own expense. So confused. I'll post again as soon as I get approved or denied.

[nightnurse]

Dockman

I have had both a bypass and a lapband... i will tell you my experience with both .... and believe me i will be more honest then you'll want to hear. I will tell i would do them both again.

Elizabeth.

[Katiegirl]

nightnurse, which do you think worked best, the lap band or the bypass? Was the recovery for the band bad? Good job on the water drinking Docman!

[Dockman4]

O.k. here's the latest...I've been approved. It's not in capital letters for a reason, I'm not that excited. As it turns out, my insurance company will only do the gastric bypass surgery, not the lap band. I kinda want to do the lap band. You all seem to be very positive about it. Less down time from work, less invasive surgery, less complications, adjustable, etc. I have the ability to pay for the lap band procedure at another hospital (center of excellence certified) but it is alot of money. Nightnurse mentioned she had both. Could you tell me which you preferred? What's the success rate for each? I've known one person who had the bypass done and gained all the weight back. So many questions, sorry, just uncertain which path to follow. Thanks in advance for any responses, you guys are great.

[MommaStone]

My doc (and I've read the same from others, including the new article posted today) that 3 - 5 years out, results between the different WLS are the same. So the differences come from the method each surgery uses to help us lose weight (band-calorie restriction; GB-malaborption, Sleeve?) and the speed of losing. My doc also said one drawback is it is not possible for docs to predict who will do well with GB and who will have dumping/malnutrition issues. This really is a personal decision. Good luck and know all are welcome here.

[Dockman4]

Thanks Mommastone. I'm going through the required weight management class so I've got a little time (a couple of months) to decide. I'll keep you posted on my decision and I'll continue to be a band2gether member...I've found a new home. We're all on the same journey, nd you guys are always encouraging to me.

[Neal R.]

If your really set on getting the band, try to do an appeal. Some insurance companies still have the band coded as experimental and that's why they won't cover it. I have heard of several people in the past appeal and win. But if you go the GB way, you know we are here for you for sure.

[Dockman4]

Thanks Neal, I'll check on that. I'll keep you guys/gals posted.