BCBS of IL

Well it al started in May of last year. I first went to the seminar that the sergicall group had. I have three friends that have WLS and are very happy that they have had it done, one of them even was a self pay. I had filled out the paperwork and sent it to the offoce. I was then called and informed about BcBs wants a 12 month supervised diet. Instead of starting the diet I juet put things off. Well 2 months ago I started to take insulin to help me control my diabeties. I was diagnosed 7 years ago but I think I was diabetic for atleast 8 years before I was diagnosed. A month after i found out about being diabetic i was diagnosed with Neuropathy. my doctor thought I was too young to have it but i must have been diabetic for a long time and uncontroled. The last time I had my labs done some protein had been spilling over into my urine. I checked out BCBS website and found the info regarding the WLS Several of the things they want me to do my doctor will not have me do, like liquid diet like Optifast and weight loss drugs. I am having my doctor wwrite a write a long letter to the ins company stating the medical nesecity of the suurgery and all of the problems that I have and that with the surgery I will be able to stop other problems berfore they start. The nurse from the surgical group thought it might work. I have contacted the hospital and have asked them to send me my medical file with all of the problems that I have had them look into and will have my doctor include it with her letter and my chart info from her office. So what do you guys think? Do you think I have a chance? If this doesn't work I was thinking of geting a lawyer. Wish me luck.

Michael, I DO wish you luck, but wouldn't count on it. I have all of the medical problems you have except I have been holding off on insulin shots while I finish month 12 of the 12 month diet and nutrition appointments. In addition I have severe sleep apnea, high blood pressure, rheumatoid and osteoarthritis, heart irregularities, gout, and a myriad of other ailments. I am required to have the 12 month despite all the problems. They won't budge on that. In addition, they're requiring 12 mo of supervised exercise. I had my next-to-final-tests today with the finale on Friday with an angiogram for a suspected heart blockage. If all is OK, I have my last nutrition appointment on March 28 and the paperwork can be sent in. I have been told by other BCBSIL clients not to expect an answer for 60 days. I have also been told that the first answer is always no. Then appeal, deny, appeal, deny et****il someone gives. Sorry to sound so negative, but I fully expect to have to fight when the time comes. If you find a way around the red tape, let me know. If I were you I'd start those appointments right away. Sherry

Sherry, Did you ever submit your paperwork to BCBS. Were you denied or are you jus doing the 12 month thing because that is what they said to do. If you did submit your paperwork to them did your PCP write a letter to them? Just curious Good luck Thanks Mike

Mike, I am in a bariatric program at Riverside Hospital in Kankakee and they submit the paperwork AFTER all requirements for insurance are met. The coordinator deals with all accepted insurances and sends in the paperwork based on what each requires. I was in the midst of the 6 month requirement when BCBS upped it to 12. She said they will not budge. I have called the company a few times and have been told it is set in stone. I have not had any paperwork submitted yet as the program coordinator said it would be denied and would use up one of our allotted appeals. I don't know how many appeals we're allowed but I didn't want to chance it. However, if you can get around the red tape I'd be thrilled for you and would feel free to use it to get around mine too. But honestly I believe it won't happen. Also the year has gone really fast. I cried buckets when they upped it, but it's almost here. Now if I can just get BCBS to cooperate I should be on my way by summer. Sherry

Mike, I forgot to answer your last question in my rambling. My PCP wrote a letter when I completed the 6 mo. portion and submitted to the Riverside coordinator. She has letters from all the physicians that have completed testing me. She has a letter from me, a diet history I wrote, and a record of my weights for the last 15 years or so. I plan on submiting my own portfolio including copies of the above, a statement about my quality of life, pictures and an exercise log for the last year suince I have been unable to enroll in an "official" exercise program. This is the only part I am unsure of. I pray they will accept this. Keep your fingerrs crossed for me. Thanks

Michael, I do not want to sound negative or cause any worry for you but I also do not think that BCBS of IL is going to budge either. My understanding is that they are really, really strict on the 12 month requirements now. Your best bet is to not sit around on your hands right now and get cracking on the 12 months of diet and exercise requirements that they have and also document it with a doctor. I tell you if we both had the same exact policy and I was denied the surgery but you were given the green light w/o you doing the requirements I would really be pissed. That would be discrimination. Everyone needs to follow the rules. That would not be right, what is good for the goose is good for the gander so to speak. Sorry to sound a little harsh but what is fair is fair. Sometimes there is a little hard work that goes along with the rewards.

Are you talking about regular BC/BS -- or HMO Illinois? I was turned down five years ago by HMO IL for surgery. I tried again last week, and was approved, after I gave my doctor a letter outlining the efforts I'd made at attempting weight loss and exercise. My doctor included that letter with a letter of her own, and I was approved immediately. No one said a word about a 12 month weight loss regimen -- only people I've read here. I think the key is the patient input, and the doctor input - instead of simply sending the forms in. I was very naive about the process five years ago, and didn't realize I could appeal. Good luck with your journey!!!

Hi Dayna, I have BCBS of Illinois PPO and the requirements are written on their website. I'm not familiar with the HMO requirements. Glad you made it through the red tape! Sherry

Hi Michael, I have BCBS HMO Illinois and I was told the same thing. I also found out that your medical group controls this!!!! The insurance said that if the doctor writes a detailed letter stating medically necessary the Insurance would cover it but they are not the ones controlling this. She (BCBS) said it all lays on your PCP medical group! I would maybe call them and ask them because if you are diabetic and have other co-morbities they need to cover this and can waive the 12 month plan. I opted not to wait and I am going to self pay because my PCP's medical group is practically making it impossible to get my referrals. My doctor is all for the surgery but the medical group she belongs is dictating on whether I can have it or not. P.S. what hospital are you going through I see we are pretty close to each other?? Charlene

Charlene I have BCBS IL PPO. My actual imsurance is a program offered by the state. It is administered by BCBS. I am self employed and due to hard times I had to drop my group health ins due to not having enough employees. My PCP is all for it. She is going to write a detailed letter for me. Seeing that this is a state program I am going to call my local state congressman and have him make a few calls for me. I have a friend that had applied for Disability and was given the run around by the government but as soon as the congressman got involved and made a few calls he was approved right away. I will not stop untill I am approved. I will even hire a lawyer if I need to. Good luck to you. By the way I am looking to have the surgery at Alexian Brothers By a surgeon from Suburban Surgical Care Specialists. Mike