BCBSofIL Help!

Hi everyone...My name is Sharon and I live in Delaware. I have BCBSofIl PPO and have just be denied for surgery. I was suppose to have surgery on Monday! I was denied because of the 12 month supervised diet. They also said that I needed 5 yrs of medical records. I can't get them because I switched drs in April and my last dr only sent 2 yrs of records. Does anyone have any advice for me on how to deal with this insurance? I have documentation of supervised diets since April but thats only because thats when I started this journey. I have tried other diets in the past but nothing has been documented. I am so depressed over this. My BMI is 51.5, have sleep apnea, high cholesterol, back problems, arthritis in my back, knees, blood sugar problems and family history of type 2 diabeties. Any help would be appreciated. Thanks Sharon

Whatever you do don't give up! Contact your doctor and ask that they send more medical records going back 3 more years. If you have tried other diets in the past then you need to sit down and document on them. Keep fighting and get all your paperwork together. My thoughts and prayers are with you!

I printed out BCBS's criteria for surgery and went over it with my doctor. She and I worked very closely together on this; she was just as committed to getting the surgery for me as I was and she freely put in a lot of time on it for me. http://medicalpolicy.hcsc.net/medpolicies/home?corpEntCd=IL1&path=templatedata\medpolicies\surg\data\SUR716.003_2005-01-18&ctype=MEDPOLICIES-POLICY&cat=SURGERY#hlink Ask for a peer reviewer doctor that your doctor can talk to. I believe after one denial you are entitled to this. Your doctor has to put the focus on your co-morbidities to make the other stuff secondary. Still, you have to show that you have made a strong effort with the 12-month diet and the medical history. I saw my doctor every month for a year and she made detailed notes so that we would be able to say I did the diet and she supervised it. By doing that we were able to get them to back down on all the other requests they made like wanting nutritional counseling, behavioral modification, and supervised exercise. Call your other doctor and insist on getting your medical records from five years back. You MUST be able to prove you've been obese for at least five years. If you only started the 12-month diet back in April they will probably not budge until more time has passed. Your only chance might be if your doctor can make a persuasive case for why further delay would be life-threatening or dangerous for you. Try pushing hard on the diabetes issue. As a last resort, some people have recommended switching to working with LivLite, saying that they are especially good at getting approvals. The closest LivLite to you would be in Pennsylvania. If the above link does not work, copy and paste it into your browser or visit bcbsil.com and search for "morbid obesity" in the providers section under medical policy. Good luck.

Sharon, Unfortunately there is no way around BC/BS' little 12 month game. However, I can tell you that once you do this 12 month program your chances of being approved are very good. You will need a documented, medically supervised intensive weight loss program for a 12 month span first and foremost. What this equates to is: seeing a dietician every month, a nutrionist every month, a personal trainer every 3 months (for the documented "increase in activity") and a psych, both at the onset of the program and at the end for the MMPI. They have gotten much more strict in their policy when it comes to approving gastric bypass or WLS altogether. So only time will help this out-keep on trying, though. Do not stop. I stopped after my first denial-was so distraught and depressed. It took me months to call my surgeon's office and get on their 12 month program, and here I am one month away from completing the program. I have lost weight and have gotten much healthier for surgery. I as well have learned to eat right and exercise. hope this helps! keep your head up