Options to Deal With BMI-Based Healthcare Denials - Part 2
In part one we talked about the issues with BMI-based denials. Today we’ll talk about your options if you are facing a BMI-based healthcare denial. Part three will be the story of someone who successfully fought these denials.
First of all, if your healthcare is being held hostage unless/until you reach a certain BMI (or lose a specific amount of weight etc.), please know that this is not your fault, even though it’s becoming your problem. Your options include finding different circumstances, fighting the denial, or trying to reach the BMI requirement. We’ll talk about each of these in turn. Note that, while the advice here may be helpful in other places, it is predominantly focused on the US experience and that it is generalized options and, as everything in this newsletter, is not medical advice.
And remember, unfortunately you are not in control of the situation, so if you are not successful, that’s not because you did anything wrong, it’s because the system is rooted in weight stigma and really messed up.
The first place to start is by finding out as much as you can about the denial. If possible, you want to get this information in writing (for example, by sending emails or utilizing a patient portal like MyChart,) or recorded (you can try saying something like “I’m afraid I won’t be able to remember everything from the appointment, do you mind if I record it?”) You can also bring someone along to take accurate notes.
Collecting as much information as you can upfront can make future steps easier. Just as a reminder, this situation should not happen. It is absolutely unfair that fat people should have to fight for the treatment that thin people get. Even if this is becoming your problem, it is not your fault. Here are some questions to start with:
Where is the denial coming from?
It is typically the surgeon, anesthesiologist, facility, or insurance
What are they claiming is the reason for the denial?
Is it anesthesia risk? Risk of complications with the surgery? Concerns about recovery time/complications? Concerns about outcomes not being as good as a thinner person’s outcomes?
Rather than offering up these explanations, you can ask more circumspectly - “what concern is at the root of the denial?” Again, try to get this answer down verbatim.
What are they hoping that weight loss will do?
This is typically tied to the answer to the question above. Getting the answer to this can be very helpful if you decide to fight the denial.
Ok, let’s look at the three main options to handle these denials. Before I start I do want to be clear that aspects of privilege, socioeconomic status, and intersectional oppression pervade all of these options and have the greatest impact on those of the highest weights and/or who are multiply marginalized.
Option 1: Finding different circumstances
Start with the information you gathered about the source of the denial. Here the fact that these limits are often applied utterly inconsistently can be helpful.
If it’s the surgeon, you can try to find another practitioner. A place to start is Mary Lambert’s Weight Neutral Provider list.
If it’s the anesthesiologist, you can see what the options are to get another anesthesiologist. One option is to ask if they offer weight loss surgery in the facility and, if so, if one of those anesthesiologists can do the anesthesia for your surgery. (This can be particularly helpful in situations where someone has been denied a surgery that they actually need/want because of anesthesia risk, and has then been referred to weight loss surgery.)
If it’s the facility, you can see if the surgeon you want to work with has privileges at other facilities that might have different BMI limits, or you can try to find a surgeon who operates at a different facility.
If it’s your insurance, then you could look at options to switch insurance coverage. Of course this can be difficult or impossible, especially if it’s your employer’s workers compensation plan. In this case you can also look at options for cash paying if that’s accessible to you.
Option 2: Fight the denial
Start with where the denial is coming from and look into the official process to challenge the decision. This may be found on the website of the facility or insurance company, or through a facility customer service representative, or ombudsman.
Some denials are easier to fight than others. For example, if the denial is coming from a specific surgeon or facility, you may have more options since these are often arbitrary. On the other hand, if you are being denied a transplant, there is more of a standardized denial not that standardization makes this any less wrong, but it can make it more difficult to fight.
If your surgeon is on board but the facility and/or insurance is not, then you may be able to enlist the surgeon to help you fight.
Before we get into the counterarguments, I want to note that these are not necessarily based in social justice, but rather in a harm reduction model of finding ways to get care in a fatphobic system.
In general, if you live in a place (like Washington, Michigan, or the Bay Area) where weight and size are part of nondiscrimination laws, then you can try using that to your favor.
You might also retain a professional patient advocate and/or attorney to help you fight if that’s an option for you financially.
I would also recommend surrounding yourself with as much support as you can, because this process can be incredibly challenging mentally since it is, at its root, a denial of your humanity.
Here are some options that have worked for folks in various situations, of course, none of them are guaranteed.
If the denial reason is about risks
Understand that what also may be at play is that surgeons are judged on their “stats” and those stats are based on thin patients (which is why it’s important that we also work to create a system that doesn’t institutionalize the idea that if fat people might not have the same outcomes as thin people, then fat people don’t deserve care, or that incentivizes surgeons to cherry-pick their patients.) For now, in this case possible counterarguments include:
They recommend weight loss surgeries to people my weight, and those use anesthesia. Perhaps we could get an anesthesiologist from the bariatric department
Ask them to provide the research that they are basing their decision on, so that you can take a look at it and/or look into research that shows that the surgery is safe at your size (Note, I currently have collected resources for joint surgery denials here, and one for gender-affirming care here, I’ll continue to create resource collections for other commonly denied procedures.)
Find/Ask what the actual higher risks are - are they minor complications that can be (relatively) easily managed?
Offer to sign a document giving your informed consent to undertake a procedure with higher risk than a thinner person might encounter.
If the argument is that you/your weight created this health issue and/or that you’re “going back to a lifestyle” that will exacerbate it:
You don’t have to accept the premise here (the tendency to blame higher-weight people’s size for, well, everything is far more rooted in weight stigma than evidence,) but you can point out that even if that’s true, athletes routinely get surgeries to correct issues that they definitely created, even though they are returning to a lifestyle that can make the treatment less effective/ long-lasting.
For example, I know someone who plays soccer recreationally – not a pro player or anything, literally plays with their friends. They are on their third knee surgery. Their surgeon said “You should probably stop playing, but if you want to keep playing, I’ll keep fixing your knee.”
The extent to which weight stigma has been codified into our healthcare system is truly horrifying and it can help us to name it when it happens.
If the reason given is that your outcomes won’t be as good as a thin person
You can point out that it’s not surprising that a system built from the ground up for thin bodies doesn’t work as well for fat bodies, so you understand that your outcomes might not be the same, but that shouldn’t mean that your desire to be, for example, in significantly less pain, or to have a gender affirmation procedure that is critical to your mental health, isn’t valid and shouldn’t be granted.
If they deny your surgery, but then refer you to weight loss surgery
You can make the case that if they are willing to do bariatric surgery, for which there are significant risks, few prognostics and almost no outcome data past ten years, then they should be able to give you the surgery that you need which likely has better data, and is also likely to have a much lower risk of re-surgery than weight loss surgery.
Option 3: Trying to Reach the BMI Requirement
Either at the outset, or after exhausting other options, some people might make the very personal decision to try to “make weight” for their surgery.
If that’s the case I think it’s important that they be aware that
Unless it’s just a few pounds, the chances of success are not very good.
Even if they are successful, the most likely long-term outcome will be weight regain, which means that they’ll have to time the procedure before they regain to a point where they no longer meet the BMI requirement
Weight cycling which is, by far, the most common outcome of weight loss attempts is independently linked to harm to health including higher mortality
The process of weight loss, especially if someone is trying to achieve rapid weight loss, could negatively impact surgical outcomes (if prolonged undernourishment improved surgical outcomes, they would recommend it to thin patients as well.)
There is always the possibility that the weight loss attempt can create/exacerbate an unhealthy relationship with food, body, and/or movement up to and including an eating disorder
If someone turns to weight loss drugs or weight loss surgery then the risks/side effects, including risks to life itself, rise significantly
This is a matter of choice for the person who wants/needs the surgery, but I also think it’s important to mention that if they lose weight (at least short-term) they are likely to get positive, weight-stigma-based feedback. This can be really difficult for someone who is forced to go against their beliefs around weight-neutral health and/or fat affirmation in order to access healthcare.
If someone is choosing this option, I would suggest thinking ahead about how to respond to this (for example: “I have no interest in weight loss and I know I’ll likely gain it all back, I’m having to lose weight in order to get a medical procedure” or “I’m really uncomfortable that you are monitoring my body – please stop, or at least stop talking to me about it” etc.). Conversely, they should take care not to engage in behaviors that perpetuate weight stigma like posting “before and after” pictures and/or celebrating the ways in which they are (at least temporarily) less exposed to weight stigma.
Having your healthcare held hostage for a weight loss ransom can be terrifying and dehumanizing. It should not happen, and if it does it becomes your problem, but it is not (and never was) your fault. You deserve the care you need and want in the body that you have now. In part 3 I’ll share the story of someone who successfully fought BMI-based denials, twice.
Did you find this post helpful? You can subscribe for free to get future posts delivered direct to your inbox, or choose a paid subscription to support the newsletter and get special benefits! Click the Subscribe button below for details:
Liked this piece? Share this piece:
More research and 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.