BMI requirements are...BS?

Some of you may know from other forums that I am currently locked in a battle w/ Aetna for VSG approval, because I have not had a BMI consistently at 35 or greater the past 2 years.  Now, it is currently right about 36 or 37, and has been trending upward those years; and, co-morbidities (Type II diabetes, hypertension, arthritis, reflux, etc.) have been around for six years or more.  But seems the good folks at Aetna have reduced all of this to a numbers game.  If you don't have the magic 35, then sorry, you're just SOL. 

My issue w/ this is I don't think that co-morbidities sit around and wait until your BMI reaches 35 to start doing damage.  Apparently some researchers agree with me:  I've been collecting some medical research about the benefits of bariatric surgery in individuals w/ BMIs less than 35.  One group at University of Texas Southwestern medical school found that persons w/ BMIs as low as 30 can have serious cardiovascular risk.  I plan to send copies of these articles in w/ my appeal letter.  I'm wondering if anyone else out there has faced a similar issue and has had success convincing the insurance goons to consider surgery w/o the "magic 35." 

Honestly, I think it would probably be easier to deal with al Qaeda than insurers. 

You have to deal with your insurance requirements if you want them to pay for wt loss surgery.  Countless stories have been on OH forums about this issue.  Even 5 years ago, when wt loss surgery was relatively new for Kaiser insurance, they had rules.  BMI rules, 6 mo. medically wt loss program within 5 years, etc.  Only issue I had was getting a written letter about the wt loss program I had paid for some 4 years preop.  I obtained the letter and I got my RNY surgery. Even better, Kaiser had opted to have a local well expereinced RNY surgeon perform surgery--outside of the Kaiser doctor pool.  You can always try to appeal.  Your insurance may have slightly different requirments for RNY surgery. OR, if the option is available, you can elect to change insurance companies.  There was a post on OH last night from a DS patient about PM'ing her to check into reduced rate wt loss surgery, if you have funds to self pay. DAVE

Wishing you success with your appeal.

If you manage to be successful with your appeal then I am sending people your way for help in the future.

I would think that you are going to need plenty of peer reviewed articles and notes from as many of your doctors as you can in support of why they believe having this surgery would be beneficial to you now rather then at a higher BMI.

Here is a link for the official journal of the American Society For Metabolic & Bariatric Surgery ASMBS. It has some peer reviewed articles there that may help you.

www.soard.org/

Thanks for the link.  Yes, I'm sure it will take a ton of literature to get them off of their numbers fixation.  Funny, I can remember when insurance companies weren't covering weight loss surgery at all.  Now they do, of course, but with new restrictions.  Who knows, in five years it may be well accepted to approve for BMI of 30 or 32 w/ co-morbidities.  But, since I'm not wiling to wait that long, looks like I might be writing the check for this one myself. That really ticks me off. 

One thing I know for sure, I will be changing insurance companies come open enrollment time this fall!

 Or it might go the opposite way.  With the non-compliance issue in Iowa, insurance companies might see this as the perfect way to stop paying for weight loss surgery completely.  If you don't know about Iowa, read the message at the top of this forum.

That is quite possible, too.  I'm sure they are always searching for a way to stop paying out their precious dollars.  To me it makes sense to pay for a surgery at a slightly lower BMI to stave off costly problems in the future, like kidney failure due to diabetes, or stroke, or other cardiovascular complications.  But I suppose that's why I'm not an insurance company CEO.  Thanks for replying.

To me it makes sense to pay for a surgery at a slightly lower BMI to stave off costly problems in the future, like kidney failure due to diabetes, or stroke, or other cardiovascular complications.

Of course it does---but the insurance company is pretty sure that by the time you develop those more-expensive problems, they won't be your insurance carrier any longer. The average American changes insurance companies every three years. They're playing the odds. They don't actually CARE about your health.

What they don't seem to realize is that while I may move on and they won't see the cost savings from me, some other WLS patient who got their surgery paid for by another insurance company will move to them and they'll get their savings from that one.

Ahh, but likely only for about 3 years, so it STILL wouldn't cover the full expenses they would have paid out for the surgery.

Now you are going to make me do math, aren't you? 

It just seems that if surgery saves money in the long run for an individual's heath costs, that it's got to save money for insurance companies in the long run. For example, if I change insurance every 3 years, and I'm in the workforce for another 20 years after surgery, at some point, I am going to come back to them on a group plan, when they can't deny me, at least for the major insurance companies. There aren't enough of them that I won't repeat.