Insurance Issues

I have epilepsy so I was going to go with the bank, but my current weight is 277 and the Doctor doesn't feel the band will be enough restriction for me.  He is suggestion the Sleeve, however, my insurance doesn't cover that unless your BMI is 50, and mine is 45.  I certainly don't want to gain weight.  The doctor said that he would write a letter of exception to Highmark, but that he has only had them overturn their decision twice.  Any suggestions?

 I'd say just have him list every physical thing that will improve for you with the WLS.  I hope they will have compassion and let you have the Sleeve.   Of course if the band is all you can get -- it is better than nothing as a tool to help you reach your goals.  Good luck!

How much weight would you have to gain to reach bmi of 50?
Honestly, I'm only asking because somethign similar happened to my aunt, many years ago.  She had the RNY back then- she had to gain like 10 or 15 pounds to make the insurance cut off- and she did it.  She said she never had so much fun gaining weight like that LOL

Are you sure that if you have co-morbidities that they will not lower the BMI requirement???  You might look into that.  Lots of insurances have 2 different BMI cut-offs depending on co-morbidities.

I wish you the best of luck!

Medicare is currently considering covering the sleeve if they do your insurance will fallow. They will be issuing a memo 3/30 on this...do you have a denial? If so is appeal and point out that CMS covers the procedure (I'm pretty sure they will). Also there are other things you can add to ur letter....like do you have the need to take nsaids? Do you have any GI issues? Just because the policy says one thing doesn't mean your fights over.....I went all the way to the benefits administrator to get my approval...if you and your Dr know its right get the surgery you know is right for you

Thanks so much for the responses.  I know it's the right surgery for me.  The doctor mentioned my hormones are out of sorts and sometimes with heavy people like myself, that can tend to make us keep the weight on.  The sleeve and the bypass change the hormones in our systems.  The by-pass is not for me.  The sleeve is.  I'm excited to start this journey though.  I'm glad that you are all here though!  THanks again!

Keep pushing for that sleeve! As a 4 yr vet with a band, they aren't worth the powder to blow them up with and don't work for most people. Personally I think they should be taken off the market. The sleeve will give you so much more success!!! Good luck to you even if you have to wait a bit to get it done!