New BCBS Requirements - HELP

OK, so this morning, I get a call from my surgeons office. Down in the valley. The assistant called at 8:30 and said to call her back. The office didnt open till 9, so I called immediately. She tolds me she was faxing the "new BCBS" criteria for medically necessary. She also told me that I cant even get in to see the Doctor if I dont have these things! They now require 2 physician supervised structured diet programs of at least 24 weeks of involvement. Over the past 24 months! I was prepared with one, from Weigh****chers, but I didnt see my doctor for that!!! It has to be in your clinical documentation! UG! I'm ready to give up, and realize this isnt supposed to happen.

Do Not give up!!! You should be able to go under the old requirements if you had already started before they changed them. I do not know much about BCBS but it sounds like they are trying to become just like Cigna. Just don't give up. We are all here for you!! Tammy

Thanks. Just really feels like spinning! I am a facts person, and I feel that everytime I get close the "facts " change. Since i had only scheduled my appointment to consult the doc, the office staff seems to want to "weed" me out somewhat UG Thanks for the pick me up... I needed it!

Rebecca, the reason you feel like every time you get close the facts change is this: Every time you get close the facts change! Cigna was the worst insurance experience of my life. They changed the facts in some pretty illegal ways. They changed the reasons for denial in the middle of my appeals process. Both denials were illegal. They had everything they said they didn't have, and presented reasons for denial -- different each time -- that had nothing to do with the legitimacy of the surgery. For example: "You didn't lose 10% of your weight" or, the second time, "You have fibromyalgia!" I doubt seriously that you'll get much cooperation from them by claiming your right to inclusion under a prior requirement. BUT, following your last denial, you WILL have recourse with the Arizona Department of Insurance. Do not hesitate to go to their Web site, get their form, print it and complete it and FAX A COPY OF IT TO BCBS. Yes, I know that you're not supposed to do this before the last denial, but you'll be amazed at the reaction BCBS has to it. Don't delay! Take action on it TODAY! Patti in Tucson Surgery Date November 7th

Ok thank you all for helping perk her up a bit. I tried (via IM) and I dont think I made a dent. (((((becky)))) don't give up on the brink of your miracle (or mine) We have to go through this together. I WILL NOT allow BC/BS to throw a stumbling block in my way (or yours!)

Never give up Rebecca, it is what they are truly hoping for. In my experience with BCBS they also require proof of being morbidly obese for 5 years, in addition to the two 24 week failed attempts within the past 2 years. Getting the criteria in writing is a huge step though because it can become your basis for getting approved. Under no cir****tances was I allowed to know the criteria. I am sure it is just like Patti says, this way they can change it according to their needs. Perhaps "not now" is the answer for you, but keep your records so in the future you can try again. I wish you the very best!~Ashlie~

You know, oddly enough, all she asked for was my psych eval. and my letter from my surgeon. I'll need to see a Pulmonologist to appease them, due to my having asthma, but that was ALL she asked for. (I picked up BCBS to get rid of CIGNA. Trust me, they SUCK. See my profile from about Sept. on, and you 'll see.) So, next wed. I see the Pulm. Dr. From there, we'll see. I'd fall over if I got approved just THAT easy, after 8 LONG months of hell and illegal denials from Cigna) Good luck!!! Michelle