BCBSIL and getting approval - what's the secret???
I have BCBSIL and have been trying to get approved for gastric banding (Lap Band) and they have denied me, although I meed all of the criteria. The stickler point seems to be the 6 month medically supervised weight loss program.....and they want an exercise program as well.
I did Weigh****cher's and although I lost weight and followed the plan, showed them documentation of my weekly attendance, etc., they are stating that I should have been going to my PCP during that time and having them document my progress. I have asked to go to a Medically Supervised Weight loss program but now they tell me that my plan does not cover that!
I also have the problem that when I call and try to get clarification on what all of the requirements are is that if you ask 10 different "Customer Advocates" you will get 10 different answers!
I know they just want me to give up and go away, but I need this surgery for my health and a longer lasting life!
Can anyone of you out there please help a California girl out???
What is the secret for approval with them??? I am so frustrated!
I have been enrolled in CURVES, Weigh****cher's, 24 hour fitness, done every over the counter diet pill known to Man! My PCP says I qualify, My WL Surgeon says I qualify....my spine doctor says it would be very, very beneficial for me to have the surgery....
They are making it impossible for me to pass their own criteria for having the surgery! HELP!!!
Also - has anyone filed for an Independent Medical Review from the Dept. Of Insurance? how did you come out and what was the process????
I know, lots and lots of questions! thank you so much!!!
Jeni
I did Weigh****cher's and although I lost weight and followed the plan, showed them documentation of my weekly attendance, etc., they are stating that I should have been going to my PCP during that time and having them document my progress. I have asked to go to a Medically Supervised Weight loss program but now they tell me that my plan does not cover that!
I also have the problem that when I call and try to get clarification on what all of the requirements are is that if you ask 10 different "Customer Advocates" you will get 10 different answers!
I know they just want me to give up and go away, but I need this surgery for my health and a longer lasting life!
Can anyone of you out there please help a California girl out???
What is the secret for approval with them??? I am so frustrated!
I have been enrolled in CURVES, Weigh****cher's, 24 hour fitness, done every over the counter diet pill known to Man! My PCP says I qualify, My WL Surgeon says I qualify....my spine doctor says it would be very, very beneficial for me to have the surgery....
They are making it impossible for me to pass their own criteria for having the surgery! HELP!!!
Also - has anyone filed for an Independent Medical Review from the Dept. Of Insurance? how did you come out and what was the process????
I know, lots and lots of questions! thank you so much!!!
Jeni
God, Please help me to move my feet!!!
Hang in there!!! I was denied 5 times before I got approved. I have the same insurance that you do. I will say that there is no exceptions when it comes to the 6 month supervised diet. You will have to go to your PCP for 6 months in a row. If you miss 1 month than you will have to start all over. This seems very frusterating but they will not approve you if you do not have the supervised diet! Good luck and if you have any other questions, please ask!!!
Kim
I dont have BCBSIL but I have Cigna for State of IL employees and they too require a 6 month presurgery diet that I got to do twice. 
I understand your frustrations. I went to my pcp. Make sure that at each visit that he/she records your weight, what you have been eating (diet plan), exercise routine followed, and any weight loss medications prescribed. I did a chart for my doctor and made sure that my records were recorded in my perment medical chart before I left the exam room at each visit. They missed a few record keeping proceedures the first round. That is why I had to do the second round. It is actually 7 months. The first visit is your initial analysis and then you go 6 times after that. Insurance companies like to test you to see how persistant you will be. Many people roll over and play dead and they dont have to pay. Hang in there and they will pay. Good luck. 
I understand your frustrations. I went to my pcp. Make sure that at each visit that he/she records your weight, what you have been eating (diet plan), exercise routine followed, and any weight loss medications prescribed. I did a chart for my doctor and made sure that my records were recorded in my perment medical chart before I left the exam room at each visit. They missed a few record keeping proceedures the first round. That is why I had to do the second round. It is actually 7 months. The first visit is your initial analysis and then you go 6 times after that. Insurance companies like to test you to see how persistant you will be. Many people roll over and play dead and they dont have to pay. Hang in there and they will pay. Good luck. 
Cat Lady
Jeni,
I have BCBSIL as well. The first time they denied me and said I needed five years of medical information and the surgeons office only submitted four. Then they said there was no medical supervised diet (which was done and there were notes) notes or clear exercise program this was in December 2007. I had seen the dietician because I am diabetic for six months and they paid for it. I got a letter from my personal trainer as well as from the health club that I attend 3-4 times a week. My surgeons office resubmitted it late January 2008. Everytime the surgeons office would call the insurance they said my file was still in review. I called them and by the end of the week I had my approval which was dated two weeks prior to that.
All I can say is that you need to keep on working at it and do not give up. Do you have HMO or PPO? If you have any medical diseases that require nutrition services the insurance will have to pay for it.
Keep up inform of what goes on.
I have BCBSIL as well. The first time they denied me and said I needed five years of medical information and the surgeons office only submitted four. Then they said there was no medical supervised diet (which was done and there were notes) notes or clear exercise program this was in December 2007. I had seen the dietician because I am diabetic for six months and they paid for it. I got a letter from my personal trainer as well as from the health club that I attend 3-4 times a week. My surgeons office resubmitted it late January 2008. Everytime the surgeons office would call the insurance they said my file was still in review. I called them and by the end of the week I had my approval which was dated two weeks prior to that.
All I can say is that you need to keep on working at it and do not give up. Do you have HMO or PPO? If you have any medical diseases that require nutrition services the insurance will have to pay for it.
Keep up inform of what goes on.
Hi there,
Yes, I have a PPO. One of the gals told me that if I have medical diseases that require nutritional services that it could not count as my 6 month Supervised Weight loss program for Surgery.
This is why I am so frustrated because I cannot get straight answers from them on exactly what I need to do. I even asked them if they would "map" it out for me in writing and I couldn't get that.
Yes, I have a PPO. One of the gals told me that if I have medical diseases that require nutritional services that it could not count as my 6 month Supervised Weight loss program for Surgery.
This is why I am so frustrated because I cannot get straight answers from them on exactly what I need to do. I even asked them if they would "map" it out for me in writing and I couldn't get that.
I do not know who told you that, but that is not true. When I went to the dietician it was for the diabetes food management. I would see the nurse as well for additional help losing weigh. I got some Xenical from her and lost about eight pounds but that was it. It is a possibly that your plan may not cover it, but everyone on BCBSIL is different. It would depend on what you employer has included and/or excluded from your coverage. I would try to work with a surgical group that will take care of all that for you. When I asked initially about WLS, I got a letter from BCBSIL stating exactly what the requirements for approval were.
I know it just does not seem right. My Surgeon told the Medical Director when they had the "Peer Review" that you (BCBSIL) make it impossible to be approved by your own criteria.
They have told me that my plan does not cover a Medically Supervised Weight Loss program..........which I find to be ridiculous since they cover WLS but maybe that is just my plan and not their fault.
They have told me that my plan does not cover a Medically Supervised Weight Loss program..........which I find to be ridiculous since they cover WLS but maybe that is just my plan and not their fault.
(deactivated member)
on 8/3/08 11:18 pm - Park Forest, IL
on 8/3/08 11:18 pm - Park Forest, IL
Hi Jeni,
I also have BCBSIL but POS plan, and all the plans are differenbt depending on whether they are a self funded plan and what the employers write into their plan as to what they want covered. Some states also regulate what must be covered.. One of the keys and there are many, is to get them to send you their criteria for wls in writing. I called cust serv and told them verbal was not good enough I wanted a paper copy,. I got 18 pages, Page 1 says BCBSIL/Provider Medical Policies, Pages 1-17are titled Surgery for Morbid Obesity.( mine covers Ill, New Nex, Ok, Tex) and there are 3 criteria that must be met. 1. BMI over 40 OR 2. M=BMI over 35 & 2 co morbidities and 3. 5 yr history of morbid obesity. Once you have that you& pcp/wl surgeon can see what you still need to do to meet the requirements. My plan would not count WW since it wasn't supevised by a MD. So I had to start in March. I am still jumping through hoops, but keeping the goal in mind, better health with or withour wls. I see a Nutritionist and a Phys. Therapist monthly. I have lost 45 pounds since my highest weight (DEC 07) and 20 pounds since I started my med sup diet (Mar). It is easy to get discourage but we have to keep trying. good luck , Paulette
I also have BCBSIL but POS plan, and all the plans are differenbt depending on whether they are a self funded plan and what the employers write into their plan as to what they want covered. Some states also regulate what must be covered.. One of the keys and there are many, is to get them to send you their criteria for wls in writing. I called cust serv and told them verbal was not good enough I wanted a paper copy,. I got 18 pages, Page 1 says BCBSIL/Provider Medical Policies, Pages 1-17are titled Surgery for Morbid Obesity.( mine covers Ill, New Nex, Ok, Tex) and there are 3 criteria that must be met. 1. BMI over 40 OR 2. M=BMI over 35 & 2 co morbidities and 3. 5 yr history of morbid obesity. Once you have that you& pcp/wl surgeon can see what you still need to do to meet the requirements. My plan would not count WW since it wasn't supevised by a MD. So I had to start in March. I am still jumping through hoops, but keeping the goal in mind, better health with or withour wls. I see a Nutritionist and a Phys. Therapist monthly. I have lost 45 pounds since my highest weight (DEC 07) and 20 pounds since I started my med sup diet (Mar). It is easy to get discourage but we have to keep trying. good luck , Paulette
BCBSIL is a pain in the behind! I did Weigh****chers and submitted my weekly weigh-in book but in order for it to be "medically supervised" I included notes from PCP visits where the doctor noted I was doing Weigh****chers and exercising. My doctor also mentioned that I followed Weigh****chers when she wrote a letter of support. I think I also may have had her physically sign my Weigh****chers weekly weigh-in book so there was no question that she had "supervised" me doing it. These are all hoops they make you jump through. I wasn't approved at first either. Don't give up!
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