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Post by sherbearmama on Dec 19, 2011 21:44:40 GMT -5
Just curious if anyone here knows the true BMI required for w/l surgery. Kaiser said it was 38 with comorbidities and 40 without. But I've just seen some literature that states it's 35 with comorbidities. I never trust Kaiser so I'm not surprised if they lied. But maybe DianaCox who lives here in CA knows the facts on this.
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Post by meredith123 on Dec 19, 2011 23:47:46 GMT -5
the guidelines are 35 with comorbids, 40 without. Not sure about the law in California, but in Michigan where I live, my insurance set their own rules. Mine requires at least 2 co-morbids for a bmi beteen 35-40, 1 co-mobid if you are between 40-45 and no co-morbids if 45 or over. My insurance has the highest requirements I've seen, most are 1 co-morbid for 35-40 and no co-morbids if you are 40 or over.
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Post by Deleted on Dec 19, 2011 23:53:55 GMT -5
Just curious if anyone here knows the true BMI required for w/l surgery. Kaiser said it was 38 with comorbidities and 40 without. But I've just seen some literature that states it's 35 with comorbidities. I never trust Kaiser so I'm not surprised if they lied. But maybe DianaCox who lives here in CA knows the facts on this. I've never heard of the BMI 38 requirement. Are you SURE? I've dealt with a lot of Kaiser patients. Are you NorCal or SoCal? I think the DMHC would overrule the BMI of 38 requirement as not being founded on NIH guidelines. On the other hand, I tried to get individual insurance coverage for my brother, and Kaiser turned him down for being too skinny - his BMI was 18.9 - the cutoff on the NIH guidelines for being underweight is 18.8, and I took it all the way to the DMHC. They came back with the conclusion that Kaiser could set their underwriting guidelines pretty much however they wanted. Fuckers.
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Post by sherbearmama on Dec 20, 2011 1:06:13 GMT -5
So, if the requirements are 35 with one co-morbidity, then when my friend (who has sleep apnea and who's bmi is 37) is denied by Kaiser, is this something the DMHC will overturn?
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Post by sherbearmama on Dec 20, 2011 1:06:30 GMT -5
Oh, and we're in Southern CA.
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Post by Deleted on Dec 20, 2011 2:36:33 GMT -5
It is certainly worth a try - I am almost CERTAIN that requiring a BMI of 38 is not founded in evidence based medicine. In fact, the FDA has approved the use of the lapband (UGH! PUKE!) for people with BMIs of 30 plus 1 comorbidity.
Tell her to file an appeal of the denial; then another to exhaust internal appeals, then she will request the DMHC for Independent Medical Review (IMR).
From the DMHC IMR Decisions database - all within the last 2 years - the DMHC sure thinks the number is 35:
MN11-11918 A 41-year-old male enrollee has requested bariatric surgery for treatment of his obesity. Findings: The physician reviewer found that this patient has a BMI of 38.3 and hypertension, a significant co-morbidity. In addition, he has failed multiple weight loss attempts. Thus, it appears the patient has clinically severe obesity along with a significant co-morbidity and meets National Institutes of Health criteria for weight loss surgery. Therefore, the requested procedure is medically necessary for treatment of the patient’s medical condition.
MN10-11813 Choi and colleagues applied the standards from the NIH, which recommend bariatric surgery for patients with a BMI of greater than 40 or greater than 35 with significant co-morbidities. The authors observed positive health outcomes in patients with a BMI between 30 and 35 with conditions such as hypertension, diabetes, GERD, and obstructive sleep apnea. Given that this patient has a BMI over the recommendation for bariatric surgery and has significant co-morbid conditions including hypertension, sleep apnea and GERD, the requested surgery has been established to be medically necessary for management of his health issues.
EI10-11545 Weight reduction surgery is indicated for patients with a BMI greater than 40, or a BMI greater than 35 with significant medical co-morbidities. As defined by the American Society of Metabolic and Bariatric Surgery (ASMBS) guidelines such co-morbid conditions include coronary disease, hypertension, respiratory issues, arthritis, and metabolic diseases including diabetes or hyperlipidemia.
MN10-11528 (They even rounded her up!) The physician reviewer found that this patient had documented a BMI greater than 35 last year with a weight of 206 pounds and with a BMI of 34.7 thereafter (2 pounds away from a BMI of 35). She also had significant co-morbid conditions including hypertension and secondary cardiovascular disease. The patient had failed prior dietary efforts, completed a multidisciplinary evaluation and was determined to be an appropriate candidate for bariatric surgery. The submitted evidence demonstrates the patient had clinically severe obesity and her BMI rounded to 35, which was the number used by the surgeon and evaluation team to determine her appropriateness for weight loss surgery.
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Post by fullhousemom on Dec 20, 2011 10:06:04 GMT -5
In Michigan, I was told by two people, one of them being a surgeon, at Sparrow Bariatric Center that they could not perform surgery on me unless I had a BMI of 35 -40 with two comorbids, or a BMI of 40. I told them that I was going to be a self pay, and they told me it didn't matter....that it was a federal law! I went to my DS surgeon, who said he had never heard of such a thing....that there was no federal law.....and I ultimately had the DS. Reading these posts, I see that some places may strictly adhere to the federal NIH guidelines. I am glad my DS surgeon did not. I was so darn close.....it would have been ridiculous for me to gain weight, risk developing comorbids, and then have surgery to lose it.
My guess is that each surgeon perhaps, has the option to establish his own guidelines...and in Michigan, insurance can establish yet another set of guidelines!
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Post by Deleted on Dec 20, 2011 11:12:20 GMT -5
In Michigan, I was told by two people, one of them being a surgeon, at Sparrow Bariatric Center that they could not perform surgery on me unless I had a BMI of 35 -40 with two comorbids, or a BMI of 40. I told them that I was going to be a self pay, and they told me it didn't matter....that it was a federal law! I went to my DS surgeon, who said he had never heard of such a thing....that there was no federal law.....and I ultimately had the DS. Reading these posts, I see that some places may strictly adhere to the federal NIH guidelines. I am glad my DS surgeon did not. I was so darn close.....it would have been ridiculous for me to gain weight, risk developing comorbids, and then have surgery to lose it. My guess is that each surgeon perhaps, has the option to establish his own guidelines...and in Michigan, insurance can establish yet another set of guidelines! There is no federal law - any surgeon can do whatever the hell he wants - the question is whether insurance can be required to cover it. For example, in Europe, there is a growing consensus that WLS should be peformed on some patients with a BMI of 30 or more. Dr. Keshishian believes that, and will do a VSG on self-pay patients with BMI of 30.
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Post by bookfaerie on Dec 20, 2011 16:31:08 GMT -5
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Post by sherbearmama on Dec 21, 2011 1:19:25 GMT -5
I got that same info from another member on OH. I don't doubt it's truth, I just think it's bs that Kaiser is feeding crap to patients making them believe that unless they have a BMI of 38 with at least one comorbidity that they won't qualify for surgery. But, then we all know Kaiser is full of latkas (just watching my language).
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Post by Deleted on Dec 21, 2011 3:05:45 GMT -5
I got that same info from another member on OH. I don't doubt it's truth, I just think it's bs that Kaiser is feeding crap to patients making them believe that unless they have a BMI of 38 with at least one comorbidity that they won't qualify for surgery. But, then we all know Kaiser is full of latkas (just watching my language). Unless that's another language, I think it's bupkes that Kaiser is full of.
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Post by sherbearmama on Dec 21, 2011 3:30:56 GMT -5
I got that same info from another member on OH. I don't doubt it's truth, I just think it's bs that Kaiser is feeding crap to patients making them believe that unless they have a BMI of 38 with at least one comorbidity that they won't qualify for surgery. But, then we all know Kaiser is full of latkas (just watching my language). Unless that's another language, I think it's bupkes that Kaiser is full of. No! I meant "latkas"! It's Chanukah so that's what's on my mind. Otherwise, I would have just said what I REALLY wanted to say, that Kaiser is full of SHIT.
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