Excessive Insurance Requirement??

[unbesleevable]

I have started the process of getting the medical clearances for my surgeon's office to send to my insurance for approval. They gave me a packet of general guidelines such as 3 support group meetings, 3 nutrition visits, etc, but advised me to call my insurance company directly to make sure that there wasn't anything extra or different that they required.

So I called Amerihealth today (I live in NJ) and provided them the service code for the sleeve and the representative said that for the sleeve procedure I need to have a BMI of "greater than or equal to 50". That kinda seems excessive to me. The packet I have from my doctors office says: "Greater than 40 or 35 with co-morbidities". Now that being said, I may already meet the requirements (At the present time) if my height is listed at 5'3 then my BMI is 51, if its listed at 5'4 my BMI is 49.88. But I was planning to try to lose 10-20 pounds before my anticipated surgery date in September. That would put me below 50 for sure.

Does anyone else have any experience with Amerihealth or another insurance requiring this? Or does it sound like the rep is nuts?

[LaffeyTaffey]

I have MVP Healthcare and unfortunately, they require me to go through a 6 month process. I had to do 3 group support meetings, nutritionist appointments, a letter from my doctor stating it's in my best interest to have the surgery, a upper endoscopy exam, and a minimum weight loss of 5% of weight. It sucks - the waiting! I still have 2 months to go.

[RehabNurse]

As far as insurance was concerned, I was very fortunate in one way and rather unfortunate in another. I have a 90/10 PPO plan through Blue Cross/Blue Shield of Texas.

Fortunately, it only took 8 weeks from the first consultation to full approval from the insurance company to have the sleeve done. I easily qualified with a BMI of 37 and one comorbidity (dyslipidemia).

Unfortunately, I've had to pay $4,500 out of pocket in various co-pays, co-insurance requirements, and so forth. After all, when you've got a 90/10 plan, you must pay 10 percent of all medical bills out of pocket. It makes me envious of the lucky people who only had to pay anywhere from $300 to $1,000 to be sleeved due to their excellent health insurance plans.

[odesskiy]

RehabNurse, just think that people go to Mexico and pay that much out of pocket, while you had it done at home. I don't know how old you are but split that money over the remaining years of your life expectancy (which is certain to increase now) and you'll realize that the money was meaningless.

I have a pretty decent insurance and would have to pay about a $1000 out of pocket. BUT, they would make me jump through all kinds of hoops for 6 months. I said screw it and paid $12K out of pocket and it was the best money I ever spent. After less than 3 months I'm down over 50 lbs, my insulin is within normal range down from 37, my blood pressure is 108/67, cholesterol way down in the normal range and everything in my blood work looks perfect. I can't put a price on that! I'm only 39 years old but I was feeling like an old man. Now I feel better than when I was in my 20's. I have been blessed with success in my endeavors, so the sum I paid wasn't a major consideration, but even if I was flat out broke I would have gladly borrowed/financed that sum.

I think since we are only a couple of months out we don't even realize how much better our futures are going to be. In a few years you will have forgotten all about the money. Think about how different your life is going to be then.

OP, sorry about the stupid insurance hoops you have to jump through. Just stick with it, whatever the outcome is. Get the insurance to pay for it, steal, borrow or beg, just get it done. It will change your life forever.