HELP! Just now "informed" I probably won't qualify for DS because BMI under 60

[galaxygrrl]

@writegirl I'm so very glad to read this. I think you have a great plan and I hope all you need is the VSG. The side effects of the DS are OK, but better not to have them.

Good luck and best wishes!!!!

 

[DSRIGGS]

Sounds like a great game plan. Best wishes to you as you fight the battle.

 

[writegirl]

@Larra @DianaCox and anyone else who might have some insight on this--so, I looked up my coverage. I was told by my surgeon's office that the BMI requirement for DS with my insurance is "60." However, after looking at the explanation of benefits (pictured in the images below) I am utterly confused. The EOB clearly states that I have to have a "BMI in excess of 60 kg/m2" in the first image to be considered for a BPD-DS. However, in the second section, the EOB states "(c) BMI exceeding 60 for consideration of the duodenal switch/bilopancreatic bypass procedure." In the third image, the EOB lists the "classes" of obesity (I am level 3).

I'm lost by these calculations. Does this not read on that first image that my BMI has to be higher than 60 kg? My weight translates into 130 kg+

On the second image it says something entirely different--BMI exceeding 60--NOT 60 kg.

Am I reading this wrong?

 

[DianaCox]

There is nothing inconsistent. BMI is in units of kg/m2 (kilograms per square meter) - the exact calculation is: body mass (in kg) divided by the square of the body height. Thus for me, at 168 lbs and 5'5" (or 76.2 kg and 1.65 m tall) = 76.2/2.7225 = 28 BMI.

Your insurance plan has a written requirement of a BMI of 60 for DS. The only questions are (1) is your BMI 60 or more, and if not, (2) is the BMI requirement medically appropropriate and/or justifiable. The answer will NOT be given in your favor by the insurance company, which wrote the stupid rule, so the only way to possibly get a ruling on it in your favor is to appeal to external/independent medical review. And in order to get to independent medical review, you have to first go through the joke of at least one and probably two internal (within the insurance company) appeals.

Buckle up - it's going to be a longish ride. But most of the time, we win this type of appeal.

 

[Larra]

What @DianaCox said. So get the surgeon's office moving on the request for authorization so you can get your denial, because you can't appeal until you get a denial. In the meantime the same document should have a section on appeals rights that will guide you (and us) as to how to proceed next. there is always an order to how appeals are done, what rights you have, etc.

 

[galaxygrrl]

@writegirl - hang in there. Diana and Larra can help

@DianaCox - would you like to define a long ride for writegirl. I saw you help Lorriane and thought it would be a long ride, but it was only a few months. So, it might help to be clear for writegirl at this

And @DianaCox @Larra you guys are the best! I wish I could help more on this board. I would like to play it forward and I find both of you, well, just inspiring.

 

[DianaCox]

3-6 months, usually.

 

[writegirl]

@DianaCox and @Larra thank you so much for clarifying that for me. I'll call my surgeon's office on Monday to make sure they have submitted for approval. They were supposed to do that a week ago, so I am sure that they would have submitted. Then again, I was sure they would inform me about any issues with insurance before 7 months of MSD and psyche eval and all this effort and expense on my end.

3-6 months scares me because of the job situation. I am applying to every position at the university and hope I can find a way to retain my insurance. I'm so appreciative of this community--you guys have no idea how much you literally make everything better. Thank you!

 

[galaxygrrl]

@writegirl. Just as an FYI, if you are going to get the DS and then loose your insurence, make sure you are aware of the lab follow ups. My labs have been a about 2 to 3K over the past 6 months and i had the surgery in Aug. My COBRA is $500 a month, so I think COBRA might be cheaper.

I know this is hard, and I wish it was not for you.

 

[Susan in Tennessee]

How often do you get labs, galaxygrr? Do you mean you use your insurance and 2-3k is what it would cost without ins ...just trying to understand, I got confused.

I got mine through Direct Labs which anyone can use unless you're in the state or two they don't service, and it was $519. I need to do again very soon.

 

[southernlady]

@writegirl. Just as an FYI, if you are going to get the DS and then loose your insurence, make sure you are aware of the lab follow ups. My labs have been a about 2 to 3K over the past 6 months and i had the surgery in Aug. My COBRA is $500 a month, so I think COBRA might be cheaper.

I know this is hard, and I wish it was not for you.

http://bariatricfacts.org/threads/did-you-know-you-can-order-your-own-labs.2068/

 

[galaxygrrl]

How often do you get labs, galaxygrr? Do you mean you use your insurance and 2-3k is what it would cost without ins ...just trying to understand, I got confused.

I got mine through Direct Labs which anyone can use unless you're in the state or two they don't service, and it was $519. I need to do again very soon.

Oh, that was what the bill said. My insurance covered most of it.

 

[writegirl]

Thank you for the information @galaxygrrl and @southernlady! @Susan in Tennessee--it's good to know about Direct Labs, too! I'm not as concerned about paying for the labs. I imagine that by the time I need to have them run, I will have another job and more insurance, or continue to work for the university and retain my current insurance. How long after DS do you need your first labs run?

 

[Clematis]

3 mo, 6 mo, 12 mo then every 6 mo forever after. Many bariatric surgeons just recommend annually but things can get too far out of control in a year. And don;t think "well I've been fine for 3 years so can skip labs for a while" as some here tanked TEN YEARS post op. You have to be diligent and lab testing and vite taking for the rest of your life.

 

[galaxygrrl]

I've have had labs about every 6 to 8 weeks, I think my PCP is a bit more cautious. She knows about the DS and has had it, but she is not used to people who went to MX, so usually the surgeon deals with the labs, so I think I'm being over tested. Feeding vampires.