advice - denied because I gained 10 lbs from edema??

You know every day I call them it gets more interesting.   I get my EOB's on line..and last night was looking at an EOB and saw there was a place to send msgs to BCBS of IL..so I fired off a letter that said this:   **************************  Please advise me status of my pre-approval for gastric RNY surgery. The additional info from my surgeon's office has been faxed on 10/09/06. I have met my duties by paying my premiums and meeting ALL your criteria you requested for this surgery, as well as using a PPO provider that is on your list that you work with....EVEN though it is a 2 hour drive for me. I have met my end and expect that you do the same by abiding by your contractual duties and approving this surgery that is medically necessary. I am in the insurance field and am familar w/contractual duties and the responsibility that you have to uphold them. AS per my paperwork submitted you will see I have met the 5 years history, MORE than 6 months of supervised diet w/my PCP & weigh****chers, my psych eval, the nutrition class, I am well over 18 and my BMI is at 50 and has been over 40 w/co morbidities for over the last 5 years. Thru weigh****chers I also received counseling for excercise..that being a member of weigh****chers and going to the meetings emcompasses all of your criteria on what the weight loss program component should consist of: every meeting at weigh****chers is about a different subject.. counseling on exercise...lifestyle changes, .....eating habits... behavior modifcation and why we eat when we do. This meets your criteria of: A program will be considered appropriate if it includes the following components: Nutritional therapy, which may include medical nutrition therapy such as a very low calorie diet such as MediFast or OptiFast OR a recognized commercial diet-based weight loss program such as Weigh****chers, Jenny Craig, etc. Behavior modification or behavioral health interventions. Counseling and instruction on exercise and increased physical activity. Pharmacologic therapy (as appropriate). Ongoing support for lifestyle changes to make and maintain appropriate choices that will reduce health risk factors and improve overall health. ** I have met everything us ask and I expect you to adhere to your contract. AND just so you know.. I am NOT going to just go away. I have rights and will enforce them accordingly. *******************   the response I got was this: **************************************  Dear Ms. Mixon: Thank you for the opportunity to assist you with your recent inquiry regarding eligibility of benefits for gastric bypass surgery. We carefully considered your request but found that gastric bypass surgery would not be eligible under your health care plan because the patient gained weight on the supervised weight plan. Unfortunately, our reply could not be more favorable. The documentation submitted has been forwarded to our appeal department and you will be notified of the outcome in 30-45 days. If you have any further questions or concerns, please contact the Customer Service Department at 1-888-652-4013 between the hours of 7 a.m. and 7 p.m. Central Standard Time or via Blue Access at http://www.bcbsil.com/statefarm/. Sincerely, Jennifer B. Blue Cross Blue Shield of Illinois Customer Service Center *****************************************************************************   I replied with this...(the are forwarding it to the appeal dept****************** ********************************************************

Thank you for your response.  I will await the appeal process.   In your policy it says nothing about successful weight loss has to be the result before approval- it simply says that "It is expected that appropriate non-surgical treatment should have been attempted ".....which it was.  The weight gain was not as a result of my diet - but if you read my notes..it is from severe edema which I was put on Lasix & a potassium pill to control the EDEMA.   Your policy reads as follows:

"It is expected that appropriate non-surgical treatment should have been attempted prior to surgical treatment of obesity

Non-surgical treatment of morbid obesity appropriateness criteria:

Medical record documentation of active participation in a clinically-supervised, non-surgical program of weight reduction for at least 6 months, occurring within the twenty-four (24) months prior to the proposed surgery and preferably unaffiliated with the bariatric surgery program.  [NOTE: The initial BMI at the beginning of a weight reduction program will be the “qualifying” BMI used to meet the BMI criteria for the definition of morbid obesity used in this policy.] ".    I would like this info and this letter to be forwarded with my appeal.  And a response received.

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Have you ever heard of this???    Can they deny it because I have gained 10 lbs from edema??

I called my benefits dept today in our corporate office and complained.   She told me that once I get the first denial...then it goes to BCBS appeals dept...if THEY deny it .then I can send it to our benefits TOTAL REWARDs appeal dept for the final decision...and the final decision is theirs ..as they are the ones who writes the policy.... 

Any Advice?

I don't have any advice for you, but I would like to offer my support and prayers.  That's scary as I am currently on the 6 month supervised diet and have lost very little weight.  I really hope I don't run into this problem too!  Besides, if we were good dieters, why would we need WLS?

That is EXACTLY what my dr. told me today...if you could lose the weight...WHY would you need the surgery??? i will keep fighting.....

Good luck with your appeal process.  My only advice would be: "You can catch more flies with honey..." If that first letter you wrote was your very first communication with BCBS it seemed pretty harsh to me.  Almost accusing them that they were going to deny your claim even before you heard back from them.  Who knows if that had anything to do with your denial or not, but remember that the people who are reviewing your file and approving/denying your request are people too and if they are offended by your tone, then they might not be as kind as you'd want.  Yes, I know that personal interactions like this should not enter into the decision making process, but they are people too and should be treated with respect and kindness. Maybe try to take a more gentle, accomodating tone in future communications rather than saying "I'm not going away, I have rights..." Just my .02 --- don't mean to be rude or mean, just thought I'd share my thoughts on how I preceived your message. Pam

It was not my first correspondence with them.   And every time I have called I have been very sweet.     I have not been difficult and always thanked everyone. This was after the first time they sent me a letter stating they needed additional info AFTER it was all sent to them.   WE resent exactly what they already had.   Then I received a denial letter after we sent them everything on their list they were looking for.    I spoked with the representative for 30 minutes and she said she honestly could not tell me why it was denied as it was all there.      She just said maybe my exercise was not prescisely documented.    Even though it was.   So I thanked her for her time and she made arrangements to send it automatically on to the appeals dept....after the additional info was approved (as my surgeon REfaxed for a 3rd time the info and a letter). That is when that email was sent....and I was not being rude...I was just letting them know that I am not just going to go away. I was not meaning to be rude.   Even in the beginning it said..."Please advise me of the status"..... but I will keep your comments in mind and try to edit and revise if it sounds to harsh. Thanks

Oh my! Is this what I face next with the national food company that my husband works for and is self-insured? Lord help all of us...

Tracy, I have Edema, and I met my surgeon last year.  I have Kaiser California, and I have to lose 10% before they will schedule me my surgery.  I have lost 18 lbs 3 times and have gained it back.  I take a lasix and it works fine, but during my time of the month (14 days) my body will hold 8-10 lbs of water.  I eat right, and still can not lose the weight.  I feel that the medical field has come a long way when it comes to this surgery, but I have yet to hear what they can do to help us lose weight before surgery, when you suffer from Edema.  I am still fighting with Kaiser. Love you, and praying for you, Miss Ladybug Annabelle