Will Insurance Deny me if I fall below 40 during 6mo diet- even after initial weigh-in above 40?

Morgan K.
on 1/12/17 6:38 am

30 years old, BMI is 42 currently.  So i am just staring out in this process and will be meeting with a nutritionist monthly for 6 months.  I have UMR insurance, and my caseworker at the surgery center said that my weigh-in weight will be what is submitted and that will occur 3 months in.  I fully understand that i must not fall below 40 prior to my weigh-in, and that means playing "the game" and not losing too much weight and all that.  what i'm wondering now is, after my initial weigh-in weight is done, should i continue on to actually try to lose weight in the last 3 months, or will insurance use that against me and say "see, you can lose weight without the surgery" and ultimately deny me?  It's a really mixed message as to what insurance is truly looking for during these 6 month diets.  Are they looking for success, which indicates you are prepared to take on the new diet restrictions?  Or do they want you to fail as proof that you have tried dieting and that just doesn't work?  i know it varies between insurances, i've read so many conflicting pieces of advice that i thought i'd try to get some answers myself.

on 1/12/17 7:01 am
RNY on 08/21/12

I've seen every combination of answers to these questions as there can be. I've seen some policies use only the start weight, and some use day of surgery weight. About the only certain answer is, they hate it if you gain anything preop.

Ask your insurer, and get the details in writing. That's the only way you can cover your butt.

6'3" tall, male. Maintaining a loss of 280 pounds.

Highest weight was 475. Consult weight 04/12 was 411. RNY on 08/21/12 at 359 lbs. Current weight 195.

M1 -24; M2 -21; M3 -19; M4 -21; M5 -13; M6 -21; M7 -10; M8 -16; M9 -10; M10 -8; M11 -6; M12 -5.

White Dove
on 1/12/17 8:01 am - Warren, OH

I was told "off the record" by my dietitian not to go below 40 before surgery.  For her to officially say that could be constituted as insurance fraud. 

I would say just don't go below 40 and don't worry about getting denied for doing it.  I cut out all white carbs and diet soda and followed a very healthy high protein diet, but did not lose to under 40 BMI.


Real life begins where your comfort zone ends

on 1/12/17 8:19 am - OK
RNY on 05/16/16

I just didn't do it. I had no requirements to lose during my pre-op time (I also didn't have to do a 6mo supervised diet, so that might play a part in it)... but I knew my BMI needed to be above 40... I may or may not have needed to gain a few pounds in order to even qualify...

Height 5'5" HW 260 SW 251 CW 141.6 (2/27/18)

RNY 5-16-16 Pre-Op 9lbs, M1-18.5lbs, M2-18.1lbs, M3-14.8lbs, M4-10.4lbs, M5-9.2lbs, M6-7lbs, M7-6.2lbs, M8-8.8lbs,M9-7.8lbs, M10-1 lb, M11-.6lbs, M12-4.4lbs

on 1/12/17 11:11 am

I was told not to go lower than a BMI of 35. Meaning I had a three pound window for three months before surgery. It was difficult but I managed. 

RNY 12/22/2016. HW 228. SW 224. CW 122

Dr. Aviv Ben-Meir. Lake West Medical Center, Willoughby OH

(deactivated member)
on 1/12/17 3:48 pm

My primary care physician told me that if I did fall below 40 insurance would not be able to pay. 

So I just decided to find the maximum amount of weight I could lose without going below 40, then I added 3 lbs as a buffer weight. Then I took that weight and divided into 6 to take into account the six months. Now every month I try to lose that monthly weight. If I lose too much I ease up on exercise to slow down my loss.

on 1/12/17 6:19 pm

Same here.  I didn't go below 40 either.   There's no need to either.  You'll lose a lot after surgery.  Just make better choices, don't limit quantity as much.  It all helps.  Just don't go under 40...

Good luck!

RNY March 1, 2017 with Dr. Reed.

White Dove
on 1/13/17 6:27 am - Warren, OH

If you go under 40, they have the right to refuse and to also deny you surgery until you have maintained higher than 40 BMI for five additional years.  It all depends on the person who processes your request for weight loss surgery.

Real life begins where your comfort zone ends

Beth C.
on 1/13/17 4:14 pm
VSG on 01/19/17

Mine was the opposite, it was the 1st appointment and then my Dr gave me a goal I need to be at by my surgery next Thursday. My insurance approved me 3 mos after my initial visit with my dropping to 39.4 BMI 

on 1/13/17 5:16 pm - Boston , MA
VSG on 12/28/16

I dropped my bmi from 42 to 32 in my 6 month preop. My doc said all that mattered was the weight at my first appointment so I think this is always dependent on your insurance.