Question:
Has anybody ever been approved without a previous 5 year history of BMI of 40?

I have a long history of a BMI of 40, but I had a weight loss of 140 lbs., that I've gained back of course. My problem is that I didn't fully gain it all back until 2 1/2 years ago - so I have the other 2 1/2 that my BMI was not yet 40. I'm so depressed about it. I can't figure out what I should produce to the insurance company. If I show my last 5 year weights, I won't have a BMI of 40 for all the years. I have a letter from my doctor stating that I weight 256 in 1987 when I first came to see her and that I now weight 270. She does say that I have tried to lose in between there and did lose over 100 pounds once, but that I have gained it all back. She state that I had other weight related co-morbities, high blood pressure, etc. and that she thinks these would greatly benefit by the loss of my weight. I have a psych eval that says I'm mentally stable. So that's all I have. One letter from my PCP and one from the psychiatrist. Is that enough? I'm afraid that I'll get denied if I just send in those two. Any ideas out there on advice of what to do?    — Rafaella (posted on September 20, 2003)

September 20, 2003
Is this a requirement of your insurance? I've not heard that it's a NIH requirement to qualify for surgery. My insurance never said anything about that although I met it no problem. I put together a detailed diet history starting at age 8, which is when I started gaining weight. I only had 5 diet attempts one which I lost about 200 lbs on and the others 40 lbs or less. The 200 lbs was in 94/95. I did debate about putting that on my info as I was afraid it would work against me. But decided I would. I also ended up trying Redux,Xenical and Wellbutrin SR after that weight loss with little to no success. BCBS never questioned anything and accepted my list as written, which was the truth. <p>Does your insurance require you PCP to submit for approval? If not, then I would have the surgeon do it and include those letters as support. You could then put a detailed diet history together and just state the facts. Do not put BMI's on there, let them calculate it. It may be that it doesn't need to be 5 consecutive years but they just want to see that this has been an issue for a long time, which it sounds like it has. Send it in and hope for the best. At least if it is denied then you will know why and can focus on that for an appeal. Hopefully it goes through fine the first time.
   — zoedogcbr

September 21, 2003
I didnt have a BMI over 40 for 5 years. I am only 20 years old, so that would have been somewhat hard, but I was approved right away. I have Delta IPA/bluecross of california. I hope everything goes well for you! God Bless!
   — Katrina K.

September 23, 2003
I'm in the same boat -my insurance company is Aetna and they require 5 year history of MO with co-morbidities. There were periods where I wasn't MO -obese, yes - but not morbidly obese. The letter your doctor wrote sounds good - the fact that you lost 100 lbs., only to GAIN it back, plus your high blood pressure should count for something with your insurance. Here's what I'm doing - Take matters into your own hands and compose a very detailed list of any and all physical problems you're having - joint or back pain? Acid reflux/heartburn/GERD? Shortness of breath? Depression? High cholesterol or blood sugar? Is your weight having an effect on your family/social life? How about your marriage or other relationship? Is it affecting your ability to perform youir job duties? Are you not able to exercise because of your weight? Do you have a family history of diabetes/heart disease/early deaths from weight related problems? Really give it some thought and put this all into a detailed letter and include a recent photo. Let your insurance know you feel your health can only deteriorate if your obesity continues and how you think the surgery could improve your health. Hope you've found something here you can use and good luck Kathi!!
   — Carly H.

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