Question:
Are the qualifications for surgery written in stone?
I've been dieting since I was 10 and I'm 50 now. Of course, after the weight loss, when I began eating normally again I'd end up heavier than when I started. I am about70 lbs. overweight. Do I have to gain 30 lbs. to qualify? — maribeth (posted on January 13, 2005)
January 12, 2005
Hi, hows your general health? If you have serious health troubles like type
2 diabetes, sleep apnea, etc, its possible to get approved at a low BMI.
There are rumors the adjustable band may get approval for lower BMIs. Lets
ALL be NICE to this new member, remember we were all once 70 pounds
overweight, and for all of us dieting caused gain:(
— bob-haller
January 12, 2005
Please read your insurance plan or call customer service and fine out what
the criteria for surgery is. The criteria most companies (and surgeons) use
is from the National Institute of Health statement regarding bariatric
surgery. Generally, you must have a BMI of 40 or greater, or a BMI between
35-40 with serious co-morbid conditions. It is not necessarily the same as
being 100lbs overwieght, because height has to be taken into account. (In
other words, 100lbs on a person 5'10" is not the same as 100lbs on a
5' 2" person.) All that being said, it is possible to have the surgery
done with a BMI less than 40 if you don't HAVE the co-morbid conditions,
but at least have the potential to develop them (family history, certain
problems that have already developed). My opinion, and I work for a
self-insured insurance company, is that nothing is ever written in
stone!(By the way, I am 48 and had the surgery at age 46, so feel free to
email me if you wish!)
— koogy
January 13, 2005
If you are hoping for your insurance to pay for a weight loss procedure,
you will have to read your policy or call their customer service (or plan
administrator) and find out what their criteria to qualify for surgery is.
You might also want to check with the surgeon you have chosen. Some
surgeons have minimal requirements before they will perform a procedure.
Each surgical group/surgeon is going to have it's own criteria. If you are
self-pay, you need only concern yourself with the surgeons criteria.
— Shayna T.
January 13, 2005
Your profile says your BMI is 31.6. I don't know how tall you are.
According to the BMI calculator on this site, though, a woman who is
5'8" with a BMI of 31.6 would weigh 208 pounds, meaning if she lost 70
pounds, she'd weigh 138 (in the low end of the "normal" range for
that height). I am 5'8", lost 130 pounds with my proximal RNY. Had I
begun at 208 pounds, I'd have wound up horribly underweight losing that
same WLS-assisted 130 pounds off that starting number. For a woman
5'4" with a BMI of 31.6, the starting weight would be 184 (70 pounds
down from that being 114, and if more yet was lost, ay carumba, you have
another seriously underweight result). You see my point here. Math was
never my strong suit, but I'm having a hard time seeing how you can have a
BMI of 31.7 and truly be 70 pounds overweight, unless we are pushing for
the "fashion-model" end of the weight-range rather than the
average person (let alone formerly obese person) range. Aiming for a
low-low fashion weight is not an appropriate WLS goal (but if I'm off on my
math on that, yikes, sorry!!). Even if it were, weight loss is not so
controllable that, in RNY terms at least, you could be sure of stopping *on
a dime* at "only" 70 pounds lost.<P>I sympathize with your
plight, having yo-yo'd up and down and up more and down for 30 years
(starting, roughly at age 10 as well), until I finally became M.O. in my
40s. Would that there had been a good, true solution to *that* problem
before I became M.O. and qualified for WLS, but there wasn't -- all I had
was diet and exercise, and the minute I stopped doing those things
strictly, I'd regain that 50 or 80 pounds I'd lost. Awful. Big problem
for lots of people. Feel for ya, I do. But WLS -- at least, not the RNY I
had (proximal one at that) -- would not have been right for me at that
stage, or I'd have become downright sickly skinny.<P>OTOH, can't say
if maybe the lap band might be a better solution to look into as it's
adjustable and all, but I dunno if they'll sew that into someone 50-70
pounds overweight or not. Perhaps you can look into that, but my guess is
any type of malabsorptive surgery that tough (if not downright dangerous to
reverse), such as the RNY and DS, would be overkill for you.
— Suzy C.
January 13, 2005
Hi Maribeth,
You really need to read and fully understand your insurance policy. Most
insurance companies will cover due to your BMI and co morbidities. Do you
have any? For example if your BMI is 45 or greater you qualify on weight
alone. if your BMI is 40-45 you really need 1-2 comorbidities (sleep apnea,
asthma, diabetes, urine leakage, high blood pressure etc.) 35-40 is 2 or
more etc. If you don't have insurance and are personal pay then it is up to
your surgeon and you. Good luck with your journey. Sonja (San Diego, CA -
RNY 9/9/04 - 334/282/222 - 150)
— Son-Son
January 13, 2005
depends on what surgery you are having, and if you want insurance to pay
for it. i doubt any doc would perform bypass--the risk/benefit ratio is
just too high. i had a bmi of 35 and had to push to get my doc to do the
lapband--and i was selfpay, no way insurance would cover me. if you are
considering the band, you might be able to find a surgeon that will take
you. i know alot of the mexican docs will do it--they seem to have the
belief that there is no point in waiting until you are 100 lbs
overweight--more preventative in nature.
— jessicamegan
January 15, 2005
When doing my research, I found that if you have a BMI of 35 with at least
one or two comorbids (read BCBS's policy on WLS) you can qualify for WLS
and this was what I was banking on since my BMI is 36+. I did not have to
gain anymore weight to be approved.
I am 5'3" with plenty of comorbids (over 5+) when submitting my
approval for WLS and was approved within one week. I am 9 days away from
having my surgery. I am only 80-90 pds overweight and having the DS
surgery. The doc wanted us to factor percentages between how much bingeing,
grazing, and sweets to determine the most successful weightloss and
maintenance program. My percentages: 50-40-10 for these areas, sweets being
the least of my problems (I love to eat!). If I had, had a higher sweet %,
then the recommendation would have been for one of the RNY types. I am very
happy with my choice of surgery type, because dumping would be a whole
other problem for me.
If you have at least one comorbid you should have no problem getting
approved. Plus I had numerous supervised diets attempts/failures to boot.
Good luck I hope everything works out...
— Toni J.
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