Everyone with BC/BS of IL-let's take a poll....

Hello Board, How are you this fine monday morning? Well I hope. So I've not seen one of these started before, and figured I wanted to know! So, those of you who have BC/BS, and are applying for insurance benefits, and those who have already been approved, please respond. Tell me if you've been denied or approved, and the reasons for your denial/approval, as well as a little note explaining your side of the story. I'll go first... I submitted for insurance approval sometime last March, I believe. I was denied due to insufficient evidence of a doctor monitored weight loss program. I am finished now w/my 12 month program, and am waiting for my "stuff" to be sent into the insurance company for approval. I hope it goes quickly! how about you? WHAT DOES IT TAKE TO GET APPROVED!!? What I am basically trying to find out here is if it really matters if you do the 12 mo. program or not, and who's been approved w/out. doing it, and who has not. does that make sense?

You can read my profile for the messy details, but long story short. Did the 12 month (actually did 5 YEARS). Did not matter. Got denied, one bullsh** reason after another. Good luck to ya!!!

Hi Meghan ... my profile has more details about my encounter with becoming approved by BCBS PPO of Illinois ... but essentially, my COMPANY had the WLS exclusion, it wasn't that BCBS wouldn't cover it. Upon appeal from my surgeon, I was approved, so I don't know what happened with my doc/ins co/employer, but I'm very glad it worked out. BCBS also now has "approved" hospitals for WLS ... I personally think getting approval through the surgeons at one of their "preferred" (for lack of a better term) hospitals makes a big difference. I didn't have to do a 12 month "diet" program (but it still took me about a year from the time I first stepped into the Wellness Institute at Northwestern until the time I had my surgery), but throughout my life I've had documented attempts (physician supervised, and non-physician supervised) at weight loss. Actually, most (if not all) insurance companies have stringent "rules", so just hang in there, and keep trying!! Best wishes to you!! Karyn

From what I've read on this board, I am the exception to the rule. I went through the Wish Center, and they submitted all the paperwork for me. (They gave me a VERY long list of paperwork/tests to be completed by the time I came in for my initial consultation, and they were able to tell me exactly what was necessary. I had my appt the 2nd week of August. I had not been on a physician supervised diet, and although I was borderline diabetic, I had not actually been diagnosed with any co-morbidities. However, the company I work for allowed WLS as long as it was deemed medically necessary. I was approved the first time around, and my approval came within less than 6 weeks, and surgery was completed less than 3 months from my initial consultation. I think it is very important that everyone remember that BC/BS has very different levels of service, and it is necessary to fully read YOUR EMPLOYERS policy. Kate Lawson 240/189/130

Mine was 3 years ago so may no longer apply. I went thru Barix, they did all the work and i was approved almost immediately. at the time the rep I talked to said the only requirement thru MY plan was 100% over the ideal weight and at 4'11 inches and a BMI over 50 - no problem at all.

I have BCBS of IL HMO. I also had a great plan thru my employer, was a BMI of 50, 180 pounds over ideal wt, 6 co-morbidities, a 7 year history with my PCP and a detailed weight history since age 16 with medically supervised weight loss programs. From the time I requested the surgery with my PCP to date of surgery was 10 weeks. Have a great day. Rich

Hi Meghan, I am Barb, I've emailed you many times about our problems with BCBS of Il. You have the PPO and I have the HMO. I started in October looking for approval. I did everything a whole year prior, but i had the wrong insurance, so I switched to a bcbs hmoi plan. But that was the beginning of another nightmare. I put a post on the board tonight, read it please. Dealing with BCBS was probably frustrating, but I was lucky enough to meet up with a wonderful customer service rep by the name of Leanne. She made sure none of my paper work was ever misplaced. That is the most important part is following up with faxed info etc. Now my biggest problem beleive it or not was with the new pcp I had, and the medical director at Rush. They took it upon themselves to develope their own "guidelines" of a waiting period of 6 months for me. But you CANNOT do that to an HMO patient. You can to a ppo patient though. Its called a pre existing condition. But even that won't count if you have had insurance coverage for at least 6 months prior to obtaining your new insurance. Anyway. Rush and the Pcp denied me twice. And then sent me off to BCBS HMOI for an appeal. Well as you know once you get into the system its harder to get an approval because now its you having to prove to the insurance you need this surgery. So what did I do. Well I just got sick and tired of all this hoop jumping and said, NO MORE...... I called my husbands employer and asked for the person who acts on the school districts behalf who writes the policy with BCBS for us. They are called Producers. So I was fortunate enough that the person I was suppose to contact was on vacation, so I thought, I'll talk to her boss. What a guy..... He and I were cut from the same cloth. At first he didn't quite beleive all that I went through, but found out later I was a victim. For lack of a better word. He contacted the upper management at bcbs and went to the root of the problem. knew who to talk to, and finally insisted on communication between the surgeon, the pcp, the hospital and bcbs. Within a week, my denial is overturned. What did I learn? Find a friend at BCBS, stick with a person who you can trust, and watch what you say, they document every single word that comes out of your mouth. If you have enough co morbids, two at least and have a bmi over 40, which I beleive you did. Then this surgery is a solution according to the guidelines of the NIH. You may not even need to do anymore dieting or counseling. The next thing I would do is contact your employer ask for the underwriter of the policy and ask for a contact name. Tell them you think you are not being treated fairly and there is a breach of contract. Tell your employer, you are tired, and you want help. I was also told that bcbs does not look fondly on reports filed with the illinois dept of insurance. Lisa Madigan has a wonderful insurance intake person who can help you file a complaint. Above all be nice to them. Tell the employer you are thinking of getting an attorney if this is not resolved soon. Again my email is [email protected]. Actually this may be new to you. Anyway email me if you need to. You have to know how to play this game meghan. Barb S.

Once I completed all of the testing I was approved within 2 days by BCBC IL HMO. My surgeon's office handled everything. I never had a problem.

. Hi Meghan! Sorry you're having problems getting approved. Do you have PPO or HMO? Over the course of the year I have spent on this site, I have noticed that PPO is turned down much more frequently than HMO. I have BC/BS HMO Illinois. I was turned down about five years ago, because the doc I had at the time didn't document my weight loss attempts. I never went in specifically for weight loss help/advice, but my weight would ALWAYS be discussed during a consultation for something else. She would suggest a diet, but as I found out, never documented any of that. In Feb 2005 I had a new doc and decided to try again. You can read my website for my full journey from then 'til now -- but to make a long story short, here is my journey: Feb 18, 2005 - Saw my PCP and requested surgery Feb 24, 2005 - Learned I was approved Mar 1, 2005 - First surgeon's appt Mar 3, 2005 - Rec'd Surgery date of 4/6/05 Apr 6, 2005 - Had my RNY Gastric Bypass Note that I am 5'1", weighed 310 pounds at the time of my doc visit on 2/18/05 and had a BMI of 58.6!!!! According to my BMI chart, I should have been approved for surgery 5 years ago, when I weighed in the 250 range. I would have had a BMI in the upper 40's at that weight. All I can say is KEEP TRYING!!!! Eventually they should approve you. Good luck to you!!!! Dayna My weightloss site: geocities.com/thedawnofanewdayna My NOLA site: geocities.com/nola_rescue

Meghan, I had Anthem BCBS of Ky in 2004. They had an exclusion so I found a job in Jan 2005 that did have insurance to cover WLS. My new employer did have BCBS of Illinois insurance- but they wanted a 12 month supervised diet. I had a 12 month supervised diet beginning in Jan 2001-Jan 2002 BUT it did not include consecutively monthly visits AND it was not in the past 24 months. After working at the new company for 6 months I thought that I would take a chance and submit my paperwork since my company is self-insured. I sent it to BCBS and was denied due to not have a 12 month consecutive physician monitored diet. I appealed with my employer and was denied for the same reason. On Jan 2, 2006 I completed my last (13th) visit to the doctor for my diet. I submitted my paperwork back to BCBS. They received it on Jan 9th. I was approved for surgery on Jan 18th. So it took 9 days for them to approve my package. I fought 19 months for this surgery. It is worth the fight. I have my surgery on Friday. **** This is what I did with my paperwork when I submitted it this time. I took the policy which lists each of the criteria (ex. ....) 1) BMI of 40 or greater or BMI of 35 or more with comorbidities.... 2) Five years of medical records 3) 12 month supervised diet 4) Consultation with Psychologists... 5) Proof of full growth..... I took a sheet of paper and typed up one criteria on each sheet. Behind that sheet I put all documents that would prove and meet their request. For the proof of full growth, I gave them a copy of my birth certificate. For the 12 month supervised diet, I included the records from the 13 visits to my doctor. I seperated each of the criteria with a tab. It couldn't have been more simple for them. It was all there. Last, I had a friend to take 3 photo shots. One head on, one to the side, and one rear view picture. This completed my package.