I'm not sure what to think.......

ok, I spoke with my PCP and she says that the phone number that I gave her that some CSR gave me at BCBSIL was not a good phone number although she did get a hold of them anyway.

They said that they have not recieved proof of any exercise program although I did send them in my CURVES documentation, which I know is most likely too old to use anyway.  It was in 2003.
She says it might just be faster for her to refer me to physical therapy and go through that for the next 6 months and get that all documented.
I called my WLS office and she said that they have left a message for the medical director to request a "peer review" and she said that they acted like she was speaking a foreign language.  She told me to keep my PCP doctor out of it because if too many people get involved then they might get pi$$ed off and will just say No.  She did ask me to call BCBSIL and get it in writing exactly what they are requesting of me and if I complete that they will approve my surgery.
So I will try to call them tomorrow and see if they will do that.  I have a hard time articulating what I want and need, I am not so good at that.
I don't know what to do. 
What if they do not give me  a guarantee in writing that if I complete what they ask that they will approve the surgery???  I just don't really trust that they will.
Has any one else gone through this? 
This is BCBSIL criteria...  Now I did my 6 months of Weigh****chers, and I qualify with my co-morbidities and BMI.

Non-surgical treatment of morbid obesity appropriateness criteria:

• Medical record documentation of active participation in a clinically-supervised, non-surgical program of weight reduction for at least 6 months, occurring within the twenty-four (24) months prior to the proposed surgery and preferably unaffiliated with the bariatric surgery program.  [NOTE: The initial BMI at the beginning of a weight reduction program will be the “qualifying” BMI used to meet the BMI criteria for the definition of morbid obesity used in this policy.]
• A program will be considered appropriate if it includes the following components:
  1. Nutritional therapy, which may include medical nutrition therapy such as a very low calorie diet such as MediFast or OptiFast OR a recognized commercial diet-based weight loss program such as Weigh****chers, Jenny Craig, etc.
  2. Behavior modification or behavioral health interventions.
  3. Counseling and instruction on exercise and increased physical activity.
  4. Pharmacologic therapy (as appropriate).
  5. Ongoing support for lifestyle changes to make and maintain appropriate choices that will reduce health risk factors and improve overall health.
  6. Well this is where I am....same place I was 6 months ago.....
  7. Have a good night, Jeni
  8.  

I am so sorry for your frustrating situation.  I don't have any helpful advise to give you, but my heart goes out to you.


Linda

 Well, doesnt every WW meting touch on some aspect of exercise.  If all you need is evidence that your 6 month program included counseling and education on exercise and increasing activity, then ask a WW leader to write a letter indicating that in the last 6 months you have been counseled to increase your physical activity in order to lose weight.  It is a core aspect of the WW program so if you participated in WW then you got this.  You dont need to go to PT to get it.  Alternately, you can show your PCP the parts of the WW program that touch on exercise and she can write a letter indicating that your program included counseling for increasing exercise and physical activity.  Heck, she's probably told you during the last six months that increasing physical activity and exercising are keys to health and weight loss, Right?  You got this covered, you just gotta get it documented.  Is this by any chance an HMO?  You can also call DMHC and ask if your insurer falls within their jurisdiction?  DMHC has repeatedly ruled that these silly 6 month diets can not be enforced by CA insurers since they are not supported by medical science.  Good luck and hang in there.  D2K   

GRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRR

Okay did I say grrrrrrrrrrrr loud enough? Okay according to your insurance wordage....I do not see how they can say you have to have a 6 month exercise program. You just need counseling on and instruction on exercise and increased physical activity.

You have better set a fire under their ass. I wish I was closer to you to help you out on the phone because girl they are yanking your chain and then acting stupid about the wordage of your policy and their requirements.

I do believe your surgeons office is right because if too many people get involved they might start stamping denied denied denied all over the place. Let the surgeon's office help you because they are the ones who are performing the services.

Give me a call tonight and lets talk!

 

Love ya   

Hi Janine,
Thanks!  I am getting ready to call the insurance company again this morning and see if they will map out exactly what I need to do.  If not I don't know what to do.
I think I am a reasonably intelligent person................but they make me feel so stupid!
I have my Grand daughter's birthday party tonite but I will call you when I can.  I'm just kind of emotional right now.  Glad I have permanent make up!  lol     I appreciate it!
Love ya!  Jeni

I just called and spoke with them again at BCBSIL and she says that Dr. Machado has requested a peer to peer review and to basically hold tight until that is done.
She says that I should have been seeing a doctor while I was on Weigh****chers and the doc should have been documenting my progress, so they would have all of the documentation on paper by a M.D.......
Ugh!!!!
Well I got to get going....I'm having some lab tests done this morning.
Have a great day all of you!!!
Jeni