Review any insurance company's denial letter for eating disorder treatment based on medical necessity, and weight or the insured's BMI (Body Mass Index), will form the basis of the denial. What is BMI and why do insurance companies refer to it as if it was the Holy Grail for determining the "healthy" weight of its insureds?
Simply put, BMI holds out an outdated, incomplete and unrealistic low weight as "healthy" and "within normal range" which insurance companies rely upon as support for denying treatment; e.g. once the patient reaches a BMI of 18 (and oftentimes less), they are considered "within normal weight range" and further residential treatment is denied. So what is BMI?
BMI is a mathematical calculation taken from the person's weight divided by his or her height squared. (Weight in pounds/height in inches x height in inches)x 703). The whole concept of BMI was first introduced by a Belgian mathematician, Lambert Adolphe Quetelet in about 1830. Quetelet was not a physician and had no medical background. Instead, he sought to conceptualize the "average man" and scientifically map the normal physical and moral characteristics of man in order to assist the government in allocating resources….in 1830. Unbelievably, however, society at large, and particularly insurance companies denying our health claims, promote and exclusively rely upon this 183 year old calculation.
"Normal" weight is defined as a BMI between 18.5 and 24.9. "Overweight" is defined as a BMI between 25 and 29.9. "Obese" is a BMI of 30 or higher. BMI makes no allowance for the relative proportions of bone, muscle, and body fat so a person with strong bones, good muscle tone and low body fat will have a high BMI.
A research team from the University of Michigan and Saginaw Valley State University measured the BMI in 400 college students finding that in most cases, BMI did not accurately reflect his or her body fat. The study cited a previous study of NFL players which found that 60% were considered "obese". According to the government standard, Tom Cruise, Sylvester Stallone, and Mel Gibson are technically obese, as are athletes Sammy Sosa, Barry Bonds and Mike Tyson. See http://www.sciencedaily.com/releases/2007/03/070305202535.htm.
To make matters worse, 35 million Americans went to sleep one night in 1998 at a government approved weight and woke up "overweight" the next morning as a result of the government changing its definition of "overweight" from 27.8 for men and 27.3 for women to 25 for both genders. Now, Will Smith, Kobe Bryant, Pierce Brosnan, and LeBron James were all considered "overweight." George W. Bush, considered by some to be our most fit President, was even overweight.
So, what does this all mean when it comes to getting our clients the treatment they desperately need for their eating disorders? Convincing insurance companies that a patient's BMI is not an accurate gauge to determine "healthy" weight will be an uphill battle. Instead, ensuring that treatment records focus on a patient's total health picture; ability to maintain this weight unsupervised, urges to restrict, low potassium or heart rate, and other comorbid conditions, helps establish medical necessity and minimize the effects of an otherwise "normal" BMI.
For more information on weight based insurance denials, contact Kantor & Kantor, LLP at (800) 446-7529.