BCBS PPO -JOKE!!

That's what that insurance is - a joke... Three people I know, including myself were denied this week! We were all given the same excuse " lack of documentation of a medically supervised diet"! They won't tell you want they need you get, or they will tell you something different each time you call! They won't let you talk to the "medical review board" to ask what they want, and they won't tell you if you will be approved if you get what they ask for! Also, we were told that you could go ahead and get the surgery, then be rembursed if they would approve the appeal, now someone said yesterday that "we don't have to pay you back because you did it before we approved it"!! They need to get their story straight! I'm not going to bother fighting with them, I've sent everything that I possibly could, and my doctor wrote the best letter I could have imagined... I wouldn't know what else to do and they won't tell you!! So, I am proceeding with self pay! If anyone does get approved, please post on this board and let us know what time of miracle you preformed to get them to approve you!! As you can tell , I am venting.... thanks for reading.... Michelle

Go to google Type in your insurance's name then gastric surgery. see if any one else with this insurance has had any success with this type of surgery. Bug them to death! appeal it. If you can wait. and save your money at the same time. have a doc record your weight every month for a year. Rack up charges on your insurance for being over weight. high blood pressure test etc... sleep test, blood work etc... See if you have any health problems . If you have gallstones etc.. you can get them out and insurance will pay for that! and at the sametime you could get your wls too. Some people change jobs to get better insurance. They want you to give up. Don't give up. work your plan. change your plan. Make your plan their plan. make them cry! till you get what you want!

Sweetie, they require 6-12 months of medically supervised diet. I don't know if that is what you were missing but most likely, it is. BCBS has really gotten strict about things. If this is what you really need, ya gotta fight for it. This is your life. It's important! Hugs Melissa

Thanks guys for your response. I did have all the requirements.. 12 mo diet. So did another guy I talk to that got denied, that's what's making me think so bad of them! I don't know why they are being so strick? But, the thing that really makes me mad, they won't let you talk to anyone who can give you a straight answer about what they really need! That's why I think they are giving everyone the run around! I don't know what to do. The lady I work with says she is going to fight it, but I really don't know if I want to bother. I will appeal, but I don't know what more info I can send them without getting a straight answer! I'm so frustrated....................... help!!

Well if you really want this surgery you fight, if its not worth bothering about then ask yourself how bad did you want it to begin with? I personally would fight if you had all their requirements that are set by them then FIGHT! Debby

BCBS doesn't consider weigh****chers "medically supervised" -- if that's whta you did.. what they want is 12 months of you going to your doctor every month for a weigh in.. following a dietary program your PCP lays out for you (if he says do weigh****chers and you do that, it's fine, but you have to weigh in with your doctor once a month for 12mos). I know it stinks.. BCBS-IL is very strict on this policy.. I wish there was something I could say to make it better. Stef

Michelle, I know how frustrated you feel, since when we decide we want something it's in our nature to want it now. But this delay could be to your advantage. You have a great opportunity here to dedicate an entire year to you - to getting everything you need to have to succeed with this lifestyle change for the rest of your life. One thing I've learned in a year of lurking here is that surgery by itself will not solve your problems or keep you thin over the long haul. There is a lot more to it than that. It is making the right choices minute by minute, day by day, week by week, month by month year in and year out. I've got BC/BS PPO and I've tried to look at the year requirement as an opportunity instead of a road block. I've been dutifully going to the doctor every month, weighing in and discussing weight, following my doctor ordered diet (WW actually!) and exercising. I also started seeing a therapist to make sure that my head's in the right place too. Because I am in it for the long haul. I do not want to have the surgery and not have all the other tools I need to go along with it to stay healthy. I do not want to lose 100+ pounds only to gain it all back and then some (something I've done before). I am using this year to get ready to be in a position to really live the rest of my life as a healthy person (who incidentally will battle food and other demons for the rest of her life, even having had surgery). Anyway, part of what I'm considering right now is putting off my surgery for another 6 months; having it in September even though I think I could actually get approval to have it in June/July. If I'm going to do this thing I am going to do it right. You've found a barrier that you cannot change - BC/BS requires a documented 1 year physician supervised weight loss program which requires monthly weigh ins and discussion of weight loss, diet, and exercise. You have 2 choices - you can continue to rail against it and complain about something you can't change or you can get tough and use the time you need to put in to make your chances of ultimately succeeding all the greater. Whether or not you fight or decide to work to meet the requirements you should get started with monthly weigh ins with your doctor now. The sooner you start, the sooner you'll be through it and you just might be better for the experience. I wish you only the best of luck in getting to where you need to be. Illini Lady

Thanks for your post. I am the guy mentioned above that got denied this week. Looks like they did a large batch at the same time. Your attitude is great. Here is the strange issue. According to the BCBS written policy, you have to FAIL at one year of Dr. supervised weight loss. That is strange. Does this mean that I need to go in planning to fail? What if I should actually lose weight? Will they deny me? Do I stop at the Baskin Robbins store each afternoon for a large shake so I am sure that I fail? Well, at least one thing. Failing at diets is something I am quite good at. I am sure I can fail at this one too!

Mitch, I know exactly how you feel about not getting any real clear direction and feeling like they're trying to outgame you. I've called them twice and gotten completely different answers each time. The only way I can aford to do this is with insurance so I have to play the game. And, the only way I can think of to make this palatable is to try my hardest/best to make the most of it. In the end it's another year of my life and I don't want to waste it. I'm really afraid too that just when I'm close to getting it done they'll move the finish line on me and change the requirements again. Ultimately though I'm really just trying to make the best of it I can. Know that it seems like a set up too. Like somehow they want you to diet so that they can point to it and deny you either way. Guess that's what the state insurance authorities are for... Sorry you got denied. But keep the faith. If you are meant to have this it will happen for you. Please stick around and keep us all posted on how you're doing. Good luck, Illini Lady

That's exactly how it feels. I have a friend who has month by month notes on weight loss attempts (not saying they are from her doctor, but she has them not the less). She is submitting her stuff this next week, so I am curious to see if they approve her. if they deny her, I know it's all a scam. If they approve her, I will fight back. Either way, i'm going ahead with my surgery and I wll try to get reimbursed. I hope you make it thru and they approve you in the end. Good luck to you and I will keep you posted! Michelle