I was denied bariatric surgery. Do I qualify?

Question

I am 46 years old, my current weight is 262lbs., I was recently diagnosed with Pre-Diabetes, I have sleep apnea, and I have at least one episode of diverticulitis a year. I don't believe that my insurance have all on my medical records since the decision was based on a doctor who saw me once and was only aware of my weight and pre-diabetes. (Just switched physicians). Can I request that my case be reevaluated?

Mark Pleatman, MD (retired) · Answer

Most insurance companies use similar guidelines to determine if patients qualify for weight loss surgery.  The most important "number" they use is the BMI, or body mass index.  This is a function of your height and weight.  If it is 40 or higher, most insurance companies pay regardless of the present of comorbid conditions.  If your BMI is between 35 and 40, they require that you have one or more of these comorbid conditions, which include Type 2 diabetes, hypertension, sleep apnea, hyperlipidemia, and arthritis.  Some insurance companies also require that these conditions are not being adequately treated with medications.  Conditions like diverticulitis or hypothyroidism don't count.You list your weight but not your height, so I can't calculate your BMI.  However, based on your weight, your BMI is greater than 40 if you are less than 5' 8", and your BMI is greater than 35 if your height is less than 6 feet tall.  So it sounds like you should qualify.

Terry Simpson, MD, FACS (retired) · Answer

Generally you can appeal a denial of service unless the service is something that is not covered by that plan (if it is excluded). From what you have it appears that you qualify. The parts that qualify are typically the BMI and conditions associated with obesity - pre-diabetes is not a qualification, but having diabetes with medications is. Sleep apnea with CPAP use typically qualifies - snoring does not. You should see a bariatric surgeon whose group is familiar with the insurance landscape and they will give you a better idea. Good luck.

I was denied bariatric surgery. Do I qualify?

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