BCBS/ ILLINOIS Denied based on no documentation of 12 mo WL failure

Hi Everyone: I just got the news that I have been denied based on no documentation of 12 continuous months of weight loss failure. I have been seeing my PCP for over three years, weight issues on and off during that time and a course of 9 months on Meridia with no significant WL. The lady at BC/BS-IL said I had to have documentation thatI was in there EVERY MONTH! I was not there every month and my Dr. didn't require me to be. I am going to see if my PCP can send in yet another letter, and more documentation. Think there's any hope for me getting this overturned? It seems to be a common problem for so many of us. I am so confused over the wording in my polity over what they want, to me it seems vague and as if they can bend it any way they want to keep denying you. Every time I talk to them I get a different person with a different story. Any advice or help would be truly appreciated. I know I am not the only one who has had trouble with this company! Cindy

Cindy - I am in no means an expert but from what I have been reading on line here, if you do not have 12 months of documentation they will not budge. From what they have been saying BCBS if very strict. PLEASE do not give up hope!! Talk to your doctor, see if she can help you in anyway. I have a different insurance, same basic problem. I am just finishing my program up and submitting to my insurance. My fingers are crossed for you!!! Best of luck, Nancy

I have BCBS IL and every policy differs. I was approved on the first try. For the months that you DID NOT see your doctor, write up your own plan. Whatever you did, diet, and excercise wise should be documented. Kind of like a journal. You could even go so far as to make up a journal of what you ate, water intake, vitamins, etc. Note if you lost or gained and how you felt week to week. Hopeless, motivated, fustrated, etc. Turn that information in to your doctor and ask that your doctor review YOUR notes. Ask your doctor to incoporate those notes in a letter and indicate that he/she is aware of what you were doing on the months he did not see you. He/she may want to piggyback on some of what you wrote. He/she may note that he/she advised patient to continue to up water intake or advised patient to increase frequency of activity, or cut back on calories, etc. He/she can also note that you continued to take your meds he/she prescribed. Review my profile if you get a chance. I may have written some info about what I did in my attempt to get approved. I don't remember exactly how much detail I went into, but I may have typed something there that may help you. Good luck and keep you head up! TJ

Cindy, WOW! I am so sorry about your insurance problems. Which kind of BCBS do you have? I was told that even if you go in monthly to get weighed, that is documentation enough! I would ask to talk to the manager of your group! Seems like they are getting some wires crossed. Also have you seen the documentation? DId your doc or nurse really document it all? That is a huge problem...they may make a brief note about it, but for some BSBS Il groups thats not enough. I hope you get this straightened out!! Good luck! xoxoxojenn

Howdy, I have BCBS PPO of Illinois and got denied last week after completing the 12 month physician supervised diet AND 12 month nutrition visits. The rejection letter asks for proof of a severly limited caloric attempt such as Optifast. It asked for more nutritional information and a 5 year diet attempt. The 5 year thing was previously sent in as were the nutritional notes. My Dr. didn't want me on a severe calorie restriction due to diabetes, but he didn't put it in his notes. So we are trying to have him write a letter saying that he doesn't want me on Optifast nor does he want me on diet pills. BCBS is stalling, plain and simple. They want us to go away and give up. But I'm digging in my heels. Good Luck, Sherry

I am so impressed with your tenasity (sp)!!I changed jobs and moved across the country to get a insurence that didn't exclude WLS (I thought BCBS would be it!) and I did all the pre-testing out of my own pocket--only to get regected because of the 12 month rule--I was given a list of 6 things I needed--- Monthly trips to the doc to get weighed,documentation of nutrician for 12 months, and documentation of exercise for 12 months--This really frustrated me --since I had 4 doctors that wrote letters of recommendation for the WLS and BCBS didn't seem to care about that..I did a appeal and had my mother (who also had WLS in the 1970's) write a letter, my sister (who is also morbidly obese) write a letter and I did a picto-graph of my weight gain---NONE of this mattered. They wouldn't budge on it. I should have gotten a lawyer---and that would have been my next step-but I won 15,000 gambling (I am a gambling counselor talk about irony) and now I am going to pay out of pocket for the Lap bad. GOOD LUCK WITH YOUR APPEAL!!!Get a lawyer if needed--it is worth 500.00 to have a 23,000 surgery paid for---After that I would say get a loan--people will finance a 23,000 car--and my body won't depreciate like a new car will!

Sherry, What you say is very disturbing to me as I'm about to finish my 12 month physician supervised diet and exercise plan (June) and am scheduled to have surgery at the end of July. I haven't been on optifast or anything like it - my doctor didn't recommend it. Sounds to me like they are stalling and just don't want to pay for any surgery. Let us all know how you do. I've already got $500 ready to go to a lawyer if (perhaps when?) I get denied. I'm also planning on getting my HR department involved. Can you get any help from your HR or union? Good luck! San

Thanks for your support, ladies. I work for a school district and we don't have an HR person exactly. Insurance issues come under the Business Manager's job description and he is brand new. I have emailed him numerous times and called several and have gotten no reply. I will keep at it. The bariatric coordinator is going to resubmit the info we have already sent and will ask my PC to write a letter stating that Optifast and medicinal intervention are contraindicated. Hopefully that will not take very long and we can go to the next level. Thanks again, Sherry