A few questions...

Hello everyone...

I have been on OH for a few years but have only recently started to post and keep up my profile. I live just south of Chicago and I am enrolled in the WLS program at U of C. I have BCBS of IL. Which leads me to my questions (I considered posting them on the insurance board but I feel my questions are IL related).


BCBS of IL's provider site states:

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.


That being said, what are they looking for with regard to: "Behavior modification or behavioral health interventions." Does a support group count or are they referring to psych counseling? Are there any WLS support groups in the Chicagoland area?

Thank you in advance for your comments...

Hi Stephanie, Welcome! 
I have BCBS of IL. I had to do a six month supervised diet, needed five years of weight history, had to have a  psych consult,   pulmonologist and  cardiologist clearance. Had to have a nutrition class (thru the doctors office), had to be willing to try a diet pill, Your surgeons office should be able to explain what the insurance needs to have done.
Good luck with your journey! 

During my approval process last fall, I was denied twice before getting approval at the first appeal. I discussed the behavior modification rules with reps from BCBSIL and was told that they are looking for documentation at least monthly from a health care professional that they prescribed a plan with goals (at least monthly), that you were compliant with the plan, were making changes to lose weight, and would therefore be likely be compliant with the lifestyle changes necessary after surgery. A support group might count if it's led by a health care professional and there's documentation in your health records at least every month during your program. They wouldn't accept your documentation in place of a  health care professional for any of their rules. You may want to call and talk to a representative to ask about what documentation they will require in your case to make sure you have everything you need for approval. Best of luck!!

Call and talk to a WLS specialist at your insurance co. Each plan within BCBS Illinois will differ. I have   Anthem BCBS, based in Ohio, and even if it had to go through Illinois, I was approved on first try.

Good Luck in your journey.

Are you looking to get the duodenal switch? (I ask because Prachand/Alverdy are Chicago's only DS surgeons). If so, BC/BS of IL gave me grief about it, so we switched insurance plans because I only wanted the DS. But when they DID approve me for RNY and Lap-Band (which I NEVER wanted--go figure) BC/BS accepted my monthly visit documentation from my psychologist as my "behavior modification" stuff. Ask them to put in writing what the accepted documentation would be for your plan, though.

As to your question about Chicago support groups, I think Dr. Alverdy/Dr. Prachand's office has a support group for its patients. I'm not sure of thei schedule or location. You can ask them for guidance on that. I'm sure others will chime in on other support groups in the area.

If you are getting the DS, I go to a great monthly support group meeting in Chicago from my surgeon, John Rabkin (from San Francisco). However, it is open to all Dsers, no matter who does your surgery. From time to time, we have some U of C patients there who need support on a given topic and then seem to disappear for a while. This meeting is held the third Monday of every month, from 6-8 p.m. at the Union League Club on Jackson in Chicago.

Also, in a separate room at this meeting, from 6-7 p.m. is always an informational session to all who are considering WLS and the DS. *Please note that it is a "history of WLS" mini-lecture and is heavily slanted toward the DS, since Dr. Rabkin unapologetically refuses to do the RNY or Lap-Band anymore, citing ASMBS stats as to success rates and quality of life issues, so if your heart is set on getting a RNY or Lap-Band...it's probably not for you.

Best of luck to you on your journey! PM me if you have any questions or if I can help in any way.

Nicolle