Medically Necessary

I am willing to fight to get an approval for my surgery. Two weeks from this Thursday we will be submitting the info to get the approval for the surgeon. I have been told to be prepared to get a denial on the first try since I have a medicaid plan and I really have no comorbidities. The only issues I have right now are : PCOS, acanthosis nigricans, depression, going to a chiropractor for hip issues, and I have plantar fascitis  and an issue with my foot that is preventing me from exercising like I should. ( I cant get into the foot dr until Jan)... I have alot of family medical history when it comes to heart attacks and diabetes.  I'm grasping at anything to prove that if I do not have this surgery I will have a premature death. I have been over weight my whole life. NOT just the last 5 years. 

Can anyone who can shed light onto my situation please help. If and when denied, what can I rebuttle with to prove to someone that I need this surgery?? 

I am freaking out. I feel like I need to be prepared if this goes the way we think its going to go.

Well i have arthritis and that got me approved with a b m i  of 36 you say you have problems with your hips is it arthritis

I should have also stated I have GERD and a BMI over 40. The hip issue is not arthritis but it is caused by my weight and the constant load I carry.

Rachel, I used New Mexico Medicaid (Centennial Care) and they approved me on the first try. I had only high blood pressure along with my 46 BMI and there was no issue getting approval. I don't know if there are differences in how different state's medicaid programs work but you might be able to get approval without a fight. You should be able to speak to someone in their customer service department that can tell you what the criteria is for bariatric surgery coverage. If they can't give you specifics, ask for a supervisor. SOMEONE has to be able to tell you what is and isn't covered and the criteria for such coverage.

Gerd should get you approved and b m I only has to be 40

The insurance can only tell me that if it is medically necessary.. Do you think GERD and my BMI will fit me into that category?

Not sure how Medicaid works, but my insurance only required a BMI of 40 or more if you have no comorbidities. A lot of the posts I've read on this site also state the same regarding the 40+ BMI.

Is there anyone you can call to get a list of requirements for approval? I called my insurance and knowing what I had to have made me feel better about the approval process.

I wi**** were that easy. I have called, my pcp has called, and my surgeons office has called and all we know is medically necessary. Medicaid isn't that easy to get an answer from and most of the reps havent a clue. I agree that alot of people are approved to BMI alone but I doubt that is going to be the case with my medicaid.. 

Get on the Medicaid website and look for the answer yourself. Most websites have medical policy criteria you can search. Most plans consider wls medically necessary with a BMI of 40, no comorbidities needed, although GERD is a comorbidity.

I have done this. There are no specifics. It just says that it can be approved if deemed medically necessary. I wi**** were clearer!! BUT I did not know that GERD was a comorbidity. So that helps!