BCBS-ppo /HELP

Hello all! I have BCBS of IL -PPO. I reside in . I have called my insurance and the plan does cover wls.I spoke to 2 reps.(no exclusion) I had to be sure. Well I have statred my 6 month supervised diet(w/my pcp). I am on mnth 3.He supports me having wls. I have also found a surgeon in my area(2 girlfriends used him).I have had my cardiologist app.,pysch eval.,and blood work done. I only have to see the nutrisionist which I will do next month.My BMI is 46. I have not lost any weight on my diet. I am also on Phentermine.1st question-Should I be worried since I haven't lost anything?I am afraid that losing weight will get me denied since they may say I can lose on my own. If I dont lose they will say too bad we wnated you to lose to show a commitmet! Also They want 5 yrs. medical history supported by medical notes. Well I don't have that . I have been ovrweight my whole life. I have only been on my job for almost 2 yrs.Therefore I did not have health insurance for the past five years.. About four yrs ago I had my appendix taken out and I am trying to get the medical notes from that to show my weight from then.I think I may have about 3years worth(yr.03-05-07). My surgeon and pcp say they will talk to them(insur. company) if there are any hurdles and write letters. The surgean and pcp are very supportive.So I guess I wanna know can I be denied for not having the 5 yrs? Can they overturn if surgean is backing me up and the pcp as well? And should worry about losing too much or too little weight? My bmi is 46 and I have mild sleep apnea(did the sleep study last month) and high cholesterol, joint pain(may be athritis awaiting results).Not to mention all my family is obese with a history of problems including heart disease, stroke,thyroid,and more. By the way I am 26yrs. old. I want to live a happy life. Thanks for listening.ANY advise is very very appreciated!I hear BCBS is TUFF!!!!!

If you don't lose weight it's ok.  As long as your doc weighs you and writes in his notes every month details about your diet and exercise.

What about not having all the proof of 5 yrs. obesity? Can help from the Surgean help me get approved? I hear letters from them and peer reveiws can help if you are missing information is that true? How many appeals do I get? 

Hello,

      I have BC/BS of NJ. I was denied twice. They said my BMI was not at 40 for 5 yaers. I was at 38 for two years. I was at 40 for the past three years. They also said I needed the weights from the past 5 years from a doctor. Look at your insurance book they want everything just as it is written. I hope you get approved good luck. For me the fight is over I have used up all of my appeals.

Depending on your history and records Horizon BCBS PPO can be very tough. Unfortunately I seem to be fighting a loosing battle (I have NJ). They appear to be very strict about the 5 year history of morbid obesity no matter what co-morbidities you currently have. As far as obtaining records that prove your BMI history consider that any of the folowing should list a weight: GYN (if female) or planned parenthood. GYM memberships (they usually weigh you when you join) School or work physicals Weigh****chers or other diet programs. Good luck and let me know how it turns out.

I also have BCBS of IL PPO - I had medical records from 1993-1998 and then from 2003 to the present to document my BMI being over 40.  So I didn't have to have the exact five years continuous, as I read the policy it says "at least" five years.  So, is there anything else you can provide to show that you have had a high bmi the whole time?  Weigh****chers booklet, any physicals from employment, any treatment at a chiropractor who has weights, records from any gym, anything?  I listed every dr I had been to and every weight related thing I had done (diets, exercise and meds), and kept the list with me because I kept thinking of things.  I didn't have to get anything other than the doc's records, but I had my list if I needed it.   Also, as Gary said, you don't have to lose on the supervised.  I did Weigh****chers and going in to my pcp each month (don't miss a month!!!!!) for weigh ins.  However, it is in your best interest to lose some right before surgery to get the liver smaller.  Also, if you read the policy, it says they use the weight at the beginning of your six months to determine your bmi, so if you lose during your supervised six months, it won't disqualify you. Finally, and my biggest suggestion, make a friend of one of the reps, maybe one you have already spoken to.  Get her extension, and ask her if you can call her for help.  This is HUGE!  (yup, I yelled and meant to).  The bureaucracy (sp) at BCBS is such that papers get lost all the time.  By having someone on the inside "in my corner" I was able to get her help to walk papers to where they needed to be and babysit my application.  IN fact, she cared so much she asked me to call after the surgery to let her know how I was, and she sent me a personal, hand written, get well card on my surgery date.  I put myself in her hands, asking for her help thru the process.  It paid off.

Good luck!

Thanks for your help! I will definitley be friendly andgget a rep. in my corner. I hear that that is ver important. Unforunatley I only have had insurance for 2 years i am missing records for 2003 and 2004. I have no visits from that time. I am still going to complete my six month diet and have them submit everything. Hopefully i wil et approved. I have a bmi over 40 and co-morbids. i'll just have to see what happens. If all else fails I will go to my HR insurance rep and attempt to get approval that way. MY v.p. at the company is very health aware and is supporting another employee that is trying to get wls. Thanks SO much for responding!

While you're doing your six months, don't give up on trying to accumulate anything you can that documents your weight for previous years.  Any records at all.  Maybe even dated photos.  Anything that you can find that gives them more years of obesity history.  The more you can give the ins co they more likely they are to approve you.  Keep thinking, you'll come up with something somewhere.  Do you know any medical professionals personally who would sign something testifying that you were obese five years ago?  Or maybe a clergy person?  Just brainstorm.  The worst that can happen is that you spend some time getting these things together and then are not approved anyway.  But the best that can happen is that you get approved because you've given the ins co enough support that this is not a new thing for you, but is your history.  Even pics of you over the years may help.  Keep working on it!  

I'm in the middle of watching Big Medicine so I don't know if my last post made much sense.  My point was that, at least in my experience, it doesn't have to be the last five consecutive years.  If you have info from prior to five years ago that shows you have a long history of obesity, that helps, too.  So, some other thoughts, if you went to any education after high school, they may have a copy of an admission physical.  Also, there may be medical records from high school (gym class records maybe?).  Even medical records from when you were in school, at any age, might be helpful.  Some women go the health clinic for pap smears, etc.  So if that was the case, they may have some medical records.  I'll keep thinking too. Good luck!