BMI 47, Help getting BCBS IL to cover DS

[irishmom1972]

Starting a new thread here. Thank you for your responses on my previous post. Tagging Diana. @DianaCox

My current BMI is 47, which is only 19 lbs away from the BMI requirement DS surgery for BCBS IL PPO to cover it.

I’ve completed my check list for bariatric surgery with my bariatric office's program, and I want them to submit the information to BCBS IL PPO for DS surgery approval ASAP. In case I get denied, I want time to appeal before the end of the year. There's a chance that my spouse's insurance might change beginning January 1, 2016 and WLS may not even be covered.

There’s no way to get in touch with my bariatric surgeon directly, and his coordinator that submits everything to the insurance for the approval is hard to reach too. I want to make sure they include everything in my BCBS request for DS surgery that will be helpful in getting me approved. So, I’ve compiled a list to send to the coordinator, because I'm sure they don't remember everything about me. When I send this to her, I'm planning on asking her to include these bullet points when they send the information to BCBS. Would you please provide me with some feedback on the following list that I compiled. Please let me know if I should take something out, because I don't want anything to come back to bite me.

Also, should I ask my primary doctor to write a letter to BCBS IL to support me for DS surgery to include now with the initial request, or should I ask him to write a letter only in the event that BCBS denies me the first time?

• I’m 5’7” (not 5’8’). My current surgeon’s office has my height at 5’8” which would make my BMI lower. Another surgeon’s office that I interviewed documented my height as 5’7”.
• Gastric bypass is not an option. I must have NSAIDs for uncontrolled migraines, fibromyalgia pain, osteoarthritis, leg cramps at night, and plantar fasciitis. Tylenol doesn’t work for me.
• Committed to high protein diet as my diet mainly consists of animal-based proteins already.
• I’m a registered nurse, and I’m very compliant to Dr.’s orders and will follow a strict vitamin regimen and a regular exercise routine.
• Just diagnosed with Obstructive Sleep Apnea via a recent sleep study. A c-pap machine is currently on order.
• I have osteoarthritis – knee pain, hip pain, and low back pain.
• Other conditions – migraines, fibromyalgia, plantar fasciitis.
• I was at a 50 BMI (BCBS's requirement for DS surgery) at some point this year in 2015, not documented at a doctor’s office officially though. In fact, I avoided doctors because I was too embarassed to step on the scale, so I struggled to get off a few pounds before my recent appointments this year.
• My BMI is 47 now, only 19 lbs away from BCBS IL’s BMI requirement for DS
• Want to have the right surgery for me the first time. Don’t want to come back for a revision in two years.
• Need pyloric valve intact so I don’t dump or dump as much.
• Big family history of diabetes, cancer, heart disease, high blood pressure
• My metabolism and hormones are highly compromised from multiple IVF treatments and a lifetime of dieting/regain. I defintely need the malabsorption for weight maintenance.
• With six young children, I need my Pyloris valve intact so I could eat like a normal-weight person. I would not have to chew every single bite to paste as RNY'ers do. I need a full functioning stomach. My lifestyle is very fast paced with six children, and it would be extra difficult to comply to chewing my food to paste. Don't want to set myself up for failure with another surgery that would be really difficult for me to comply with (will this statement come back to haunt me if DS is absolutely denied and then I end up going with Sleeve Gastrectomy?)
• I need to drink with my meals. Chronic sensation of dry mouth.
• I want to look normal to others when eating, not 2 oz meals.
• Most other BCBS plans in other states cover DS for patients with BMIs over 40 and no cormid conditions.
• DS surgery is the platinum standard for weight loss, and it will provide the best long-term success for me. Among my six kids, I have two daughters who are overweight. DS surgery will give me the best chances for long term success with a healthy active lifestyle, and my daughters' will learn to live that same healthy, active lifestyle as I will be their role-model.

 

[southernlady]

Okay, take out the points that deal with kids, how you look to others, etc and stick to the medical facts.
Such as the requirement for NSAIDS
The c-pap
And get a actual height on record with your pcp/surgeon...tell them you want to slip off your shoes.

 

[irishmom1972]

@southernlady Thank you! What about this one in my original post..should I leave it in or take it out??....

"With six young children, I need my Pyloris valve intact so I could eat like a normal-weight person. I would not have to chew every single bite to paste as RNY'ers do. I need a full functioning stomach. My lifestyle is very fast paced with six children, and it would be extra difficult to comply to chewing my food to paste. Don't want to set myself up for failure with another surgery that would be really difficult for me to comply with"....

 

[southernlady]

@southernlady Thank you! What about this one in my original post..should I leave it in or take it out??....

"With six young children, I need my Pyloris valve intact so I could eat like a normal-weight person. I would not have to chew every single bite to paste as RNY'ers do. I need a full functioning stomach. My lifestyle is very fast paced with six children, and it would be extra difficult to comply to chewing my food to paste. Don't want to set myself up for failure with another surgery that would be really difficult for me to comply with"....

That is emotional, not fact based. As much as you want it, they honestly DO NOT CARE!

 

[Munchkin]

SEEE! I told you were not 5'8". 20lbs... Go out to lunch!

 

[Larra]

2 things - 1) when you get your height rechecked, do it at the end of the day when you are at your shortest

2) leave out stuff about not wanting a revision in 2 years - makes it sound like you are not going to be compliant, leave out the stuff about the kids, leave out the stuff about wanting to look normal, etc etc. Stick to MEDICAL NECESSITY.

I'm hopeful that you have enough here to persuade the docs at U of C to offer you a DS with a bmi below 50, much less certain about getting insurance coverage. They can be real sticklers because it's not really about you and yout health, it's about spending as few $$ on you as possible. Sorry, but that's reality.

Oh, and they don't care about your daughters' health, either.

 

[Clematis]

We're used to inhaling and standing tall when getting measured. Exhale and collapse.

Put a couple of those 3-5# soft ankle weights in your underpants. Put another pair of soft wrist weights in your bra.

 

[southernlady]

Put a couple of those 3-5# soft ankle weights in your underpants. Put another pair of soft wrist weights in your bra.

THAT would be considered fraud.