Insurance and qualifying co-morbidities?

My RNY surgery date is February 14th and have both primary and secondary insurance. I've diligently crossed my t's and dotted my i's on following insurance requirements and have met every hurdle with a start BMI greater than 40 (and pre-authorization to proceed), lost 5% of my weight and conducted every MD office visit necessary (sleep study, psych, nut., etc.) and have co-morbidities. I am excited! I'm now doing the pre-op limited intake to shrink my liver for laproscopy.

Late yesterday afternoon the program coordinator emailed to inform me that the insurance denied the surgery because hypothyroidism is not a qualifying co-morbidity. I and she already knew that. I have other co-morbidities (not diabetes or sleep apnea though). The surgeon requested a peer to peer review of my case with the insurance medical director and the soonest scheduled availability was Wednesday 2/13 at 8:00am. I'm told he has a high rate of success with the insurance company on these issues. Needless to say I'm on pins and needles and ticked that I won't know anything until the day before surgery.

Does anyone know where I can find a comprehensive list of insurance qualifying co-morbidities for RNY? I'd like to at least feel I'm somewhat knowledgeable since right now perceive I have no control over what the insurance determines.

Thanks for the help,

Dania

Hello and first im sorry this happened.

The first place to start would be with your insurance company..I'd imagine this is the ONLY place that can tell you THEIR approved list of co-morbities. I found mine in my insurance book my job gives us every year.  Now a days it's located on my insurance companies web site (i to was double insured)...if you can't find it there you should call them and ask where you can find this information ..etc. 

I say all that because each insurance company has their OWN set of rules and qualifiers. It should be laid out in black and white in some insurance manual/document you have. 

Good luck and I hope you get to join us on the losers bench!

Below is a list of co-morbidities as listed by the National Institute of Health. They do say that your insurance company may not use them all. The last one made me chuckle. Premature death, that would exclude you in my mind - too late! Usually if you have a BMI of 40 or more you don't need to have co-morbidities. I have highlighted in red the ones that I am familiar with that are more commonly talked about on this forum. There may be more that are common that I am not familiar with or haven't heard about.

Obesity Comorbidities

To follow is a list of comorbidities (additional conditions or diseases) related to obesity which may help you in qualifying for weight loss surgery.

• Family history of heart disease
• Family history of stroke
• Family history of diabetes
• Family history of heart attacks
• Hyperinsulinemia
• Diabetes
• High blood pressure
• Coronary-artery disease
• Hypertension
• Migraines or headaches directly related to obesity or cranial hypertension
• Congestive heart failure
• Neoplasia
• Dyslipidemia
• Anemia
• Gallbladder disease
• Osteoarthritis
• Degenerative arthritis
• Degenerative disc
• Degenerative joint disease
• Recommended joint replacement from specialist
• Accelerated degenerative joint disease
• Asthma
• Repeated pneumonia
• Repeated pleurisy
• Repeated bronchitis
• Lung restriction
• Gastroesophageal reflex (GERD)
• Excess facial & body Hair (Hirsutism)
• Rashes
• Chronic skin infections
• Excess sweating
• Frequent yeast infections
• Urinary stress incontinence
• Menstrual irregularity
• Hormonal abnormalities
• Polycystic ovaries
• Infertility
• Carcinoma (breast, colon, uterine cancer)
• Sleep apnea
• Pseudotumor cerebri
• Depression
• Psychological/sexual dysfunction
• Social discrimination
• Premature death

Good luck with the appeal!

Martha 

It varies from insurance to insurance.  You can call your insurance company and ask.

If your starting BMI was over 40, do they require a comorbidity?  Usually they don't if your BMI is over 40.