Fighting BMI-Based Denials Part 3 - Patient Experience

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In part one of this series we looked at the phenomenon of BMI-based treatment denials. In part two, we looked at resources to fight these denials. Today we have a first-person patient experience.

Beckie Hill is someone who had to battle to have the surgeries she needed, and it’s a battle she won, twice. So I asked her to share her story for the newsletter and she graciously agreed! The rest of this piece is in her words:

I injured both my knees on 08/17/2019 while working. I had x-rays done, followed by a round of physical therapy, massage, medication, activity limitation, taping, and injections. It did not improve my range of motion, activity tolerance, and/or pain. At that time, my physiatrist and primary care physician referred me to an orthopedic surgeon. I saw him on February 3, 2020. He recommended surgery right away, for both knees, and requested authorization for the surgeries through my worker’s compensation insurance.

On 02/19/2020, the utilization review (UR) company for the worker’s compensation insurance provided the following decision: “Recommend denial. Failed to meet the criteria for TKA since her BMI is ##, and the Medical Treatment Guidelines (MTGs) require the BMI to be less than ##”.

The UR makes a recommendation to the worker’s compensation insurance and they can then agree or disagree with the UR’s recommendations. Worker’s compensation chose to deny surgery.

I began the search of scholarly articles supporting knee surgery in larger-bodied patients. [Editor’s note – you can find a collection of those here.] I reached out to professionals within the weight-neutral community for articles, ideas and suggestions. My surgeon also provided documentation to worker’s compensation. He also had phone calls with the medical director. On 04/20/20, my surgeon informed the medical director that I would be in a wheelchair within 6 months.

Worker’s compensation still denied the surgery.

Worker’s compensation directed me to lose weight or undergo intentional weight loss surgery. The suggestions and denial of medically necessary surgery re-activated a pre-existing eating disorder of atypical anorexia and bulimia. I lost weight, but I was also very sick. I met with an intentional weight loss surgeon during this time, told them about the need for knee surgery, direction to lose weight, and my eating disorder. This surgeon emphatically indicated that weight loss was contraindicated for me from a nutritional, medicinal, and surgical basis. ***Please note, I would NOT have undergone surgery and have been offered weight loss medications many times and refuse to take them.

Worker’s compensation was provided with documentation from the intentional weight loss surgeon and still denied the surgery.

I ultimately retained an attorney to help me navigate this system given the stress and toll the process had taken on me.

I was ultimately provided with a cane, walker, an electric scooter, and a disabled parking permit. I lost the job that I was injured at because they were not able/willing to accommodate my work restrictions. Commuting to my place of employment after that became very difficult, and that employer was not able to continue to accommodate my work-from-home status as they had during much of the pandemic. My third job wanted me to work more hours than I was released to do, even though I did try.

My lawyer, worker’s compensation, and the attorney general had months of discussion and both knee surgeries were ultimately authorized. I had my right knee surgery on 12/29/2021, 680 days after the orthopedic surgeon’s recommendation. In June of 2022, my surgeon provided surgery information for the left knee surgery and worker’s compensation denied that surgery, again due to BMI. It was ultimately authorized and occurred on 08/10/2022, 904 days after the initial surgery recommendation.

Did I ever get close to the BMI that the MTGs “required”? No, in fact, based upon the UR reports I have seen, it went up. It was far more important for me to nourish my body so that I could try to navigate life and recover from surgery if it was/were ever authorized.

Not only has the denial of the surgery for each knee been physically traumatic, but it has also been professionally, mentally, emotionally, and financially devasting. I am an “N” of 1. I am not a BMI number. I am a human with a body that is different than every other body on this planet.

I am doing okay with the knee recovery. Both surgeries went well and I have almost full ROM in my right knee, and I am about 5 weeks out from the left and doing more movement than the first surgery. There were no complications during or post-op, no issues with wound healing, and while I still have some pain, my surgeon did not anticipate being at maximum medical improvement for one year post-op.

I had a surgeon willing and able to do the surgery. And yet, an archaic system and humans within that system made decisions about my body and my life using a system created in the 19th century. The BMI is an abhorrent way for insurance companies and medical providers to render decisions about people. It was not developed to make these decisions, and yet “we” are still making medical decisions and judgements based upon BMI alone.

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I am so grateful to Beckie for sharing her story, even though it’s a story that should not have to be told, because it never should have happened. If you are dealing with a BMI or weight-based denial of care, know that you deserve far better.

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More research and resources:
https://haeshealthsheets.com/resources/

*Note on language: I use “fat” as a neutral descriptor as used by the fat activist community, I use “ob*se” and “overw*ight” to acknowledge that these are terms that were created to medicalize and pathologize fat bodies, with roots in racism and specifically anti-Blackness. Please read Sabrina Strings Fearing the Black Body – the Racial Origins of Fat Phobia and Da’Shaun Harrison Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness for more on this.