BC/BS HMO IL -- Medically Supervised Diet

I feel really disheartened. Along with all of the usual testing and stuff, the insurance wants 'documentation of a year long medically supervised diet'. I have had the same PCP for 8 years. He has watched me yoyo on WW, Jenny Craig, Adkins, etc. etc. ad naseum. This has been a crappola week all the way around. (cross posted on IL and general board) So, does anyone have any experience with this insurer and/or can anyone shed light on what this means. Anyone been able to get by without this. If so, what did you do? Any advice, referrals to a webite? Any help at all will be helpful. I am sitting here blubbering over this, even before I can talk to my PCP or the surgeon's office. They already gave me a date (the date I requested in Dec.). It has just been a bad week all the way around. I won't give up but I do want to crawl in a hole right now. Thanks for reading my drama.

Katie I have BCBS of Il as well and have been doing tons of research and calling as to what they really mean. Here is a link to an old post - and when I called and questioned the rep about what they want, I got pretty much the same response. luckily, I have been under a doc supervision since 2000 and going in MONTHLY for weight/vital checks AND meeting with a nutritionist. I have not submitted yet, so I am not sure if that will even be good enough for them. Anyway, here is the post - so good luck and keep us posted as to how it turns out http://www.obesityhelp.com/morbidobesity/insurance-help/postdetail/3448.html?vc=0

Thanks Patty -- How very depressing. Right now, I don't feel like i could handle fighting the insurance company. After reading that thread, it seems so unlikely that it will come through, even with diet and exerise for a year bsbs might deny anyway. The surgeon's staff member told me that BCBS of IL HMO has covered patients in the past -- they did not talk to me about a year long diet. They covered so much material, why wouldnt they mention that? Oh well, guess I might be just stuck for now.

http://www.wishcenter.org/new/press_release1117.asp I just found the above link. I didn't choose the wish center -- but I wonder if this means 'agreement to cover' after a medically supervised diet. Hmmm, dunno.

I went through WISH (May 2003) but it was back before BCBS started the 6 or in some cases the 12 month supervised diet, blah blah. At that time WISH did not accept any insurance but now I guess that they accept some and one of them being BCBS is in network for them. By my saying not accept, they were not in network with any insurance. My insurance paid 80% and my husbands picked most of the rest. WISH does have a practice diet that you are guided through for 8-12 weeks. The time frame depends on how much guidance a person needs, I did mine for 8 weeks. This practice diet is explained after you first go to their free seminar and then have your first pre-op appointment. You are to eat 6 times a day, 3 meals and 3 snacks. Are given an indiviualized exercise program to follow, note it is indiviualized. They work with your limitations and have you exercise with things you like to do. Then you are to start taking all your vitamins/minerals at that time. Drink the recommended amounts of water in a day. All this info is to be logged on sheets that they provide you. All of this is meant to help you start learning the new healthy eating and lifestyle that you will have when you are PO. Now, I do not know if BCBS will accept this 8-12 week program in lieu of the 6-12 medically supervised diet attempts. You would have to contact both your carrier and WISH for those answers. There is a lady on this forum by the name of Rebecca Isby that is going through the WISH program right now. She does have a post a couple of days back. You could contact her if you have any questions regarding WISH etc. There are a couple of other ladies that responded to her post that also went through WISH. One of them has the same insurance carrier as you. Good luck.

Thank you very much Christine. I have a much better attitude about this 'fly in the ointment' today. No-one said it was going to go smoothly. I will do whatever it takes to there, including investigation the WISH center. Thanks again Katie

Oh Katie....get your constitution up for a fight with these guys! I had BCBS/IL PPO up until this month when I literally switched teaching jobs to get another insurance. Last year after my second denial from them (with a lawyer and proof of the 12 month diet) I was in the pits too. The second denial stated "lack of nutritional support such as Optifast or Medifast for one year" The first denial was because I didn't have MONTHLY documentation from my physician. I have done everything humanly possible to fulfill their requirements, and then they just invent something new to deny me on. I suppose I could have done more legally and fought them with a letter from the PCP saying he advised me against optifast...but I had had it. It was literally easier to switch jobs and insurance companies than to fight them any longer. I don't mean to crush your plans....but I doubt very much there is any way around the 12 month diet, even with it, they denied me because I didn't try optifast. I found them very disinterested in their customers, unknowledgeable and not helpful in the least. I could go on and on....but what's the point. Start your 12 months or get the documentation if you have already done that. Time will pass, you'll see. But my heart goes out to you, because I have felt the pain of multiple denials from this place. It is terrible. Now I am starting all over....still very much hell bent on having this surgery one way or another. I am getting the paperwork together for the new insurance company and fulfilling their requirements which are a breeze compared to BCBS/IL PPO! I trust that when I am supposed to have this surgery, it will happen for me, and it will for you too. I had hoped to have had it over a year ago, but it didn't work out that way. Time passed very fast, and here I am still trying. I send you all the best of luck...and who knows you may be one of the lucky ones. As near as I could ever guess I think they just approve a person here and there to keep their butts out of serious trouble. I was not that person, but I hope you are! Keep your *****or chins up in the case of me)! Hugs- Cindy

Thanks Cindy~ Yeah -- it does suck. One thing I know, I cannot do Optifast -- I am pretty sure I qualify for the medical exclusion. Who knows what will happen. I am a pretty good fighter, and I plan to research the hell out of what I need to do in order to fight this. Meanwhile, I left a message for the staff at the surgeon's office and I suppose they will get back to me on Tuesday. The weird thing is that there are people *****cently, has both the exact same surgeon and insurance and who mention on their page that they had no prob. with the insurer. Oh well, gotta wait and see what happens! Katie

Hi Cindy and Katie! How are you girls doing after the holiday weekend? Okay, let me shed a little light hopefully on your questions-to Katie. Katie-BC/BS requires-mandates-etc. that any one applying for insurance coverage for bariatric surgery undergo an "intense medically supervised diet". This means that you see a nutrionist and dietician every month, every 3 months you see a personal trainer, and twice in the 12 month period you see a psych doctor. This shows them that you are 1-willing to make a long term commitment, and 2- that you are attempting yet another diet just to find out you'll fail, but, in their eyes you're trying again. Now, I am not sure about Cindy's specifics as that sounds like shady and illegal and deceptive practices for BC/BS to deny her after her 12 month diet plan. BUT- I had wondered if Cindy had been seeing the same doctors I am every month? 2 people every month, discussing eating habits, new changes to your lifestyle and how you can continue to change, etc. And actually applying those changes to your life. I never know w/each person's program as they are all different, so I am not sure on her specifics. But, I was basically guaranteed by my surgeon's office (after numerous meetings w/reps from BC/BS to develop and tailor this "special" program) that I would be approved for surgery in 12 months. I am now 3 months shy from my "goal". I've not heard any thing negative from my surgeon's office about their patients not being approved after strictly following their "plan", in fact I know I've been told to start preparing and thinking ahead to my surgery, etc. In due time, my surgeon will be presenting my case for insurance approval and of course I will know more at that time. I would find it hard and difficult to believe that they deny, after completely complying with their requirements, surgery based on the fact taht you didn't take optifast or the other crap that doesn't work in the long run. I would say that is definitely grounds for lawsuit and reports to the BBB and your attorney general's office. Maybe Cindy can help us out and tell us her exact regimen so we can compare and find out what our fate will be!!! good luck and persist!

Things are looking better on this end after talking to the insurance company and to my surgeon's office. It looks like my 12-13-05 date will stand! woohoo! Thanks again to all who provided support and information. This is a really good resource thread! Katie