BC/BC Illinois ???

I am just beginning my journey for WLS.  I am hoping for the Lap Band.  I was wondering if anyone has had any experience good or bad with BC/BS of Illinois PPO.  I have read through some of the posts and there is not a lot of info for BCBSof IL.  My plan requires 6 months under doctor supervised and BMI greater than 40.  I have both the doctor care and BMI of 43.  Also my PCP is very supportive and will be submitting the letter to the insurance company.   Does anyone have any advice or forsee any problems that I might be facing?  I know this is one of the most difficult parts of the whole process.  Thanks for any insight that anyone might be able to provide. Kim

Hi Kim!

I also have BCBS of Il PPO.  I am fighting them right now.  But I am trying to get the DS, which they do not cover... yet!!  They do cover the lapband, so you should be okay.  Just jump through all of their hoops.  I have heard of lots of people getting denied the first time (people from my husband's work).  But I don't know if they aren't doing what they need to do, or if BCBS just generally denies the first time.  I tend to think its the latter.  Make sure your dr. is very descriptive on your visits with him... bmi, weight loss or gain, what you are doing for exercise, etc. 

You may get approved the first time, and you may have to appeal.  Either way, you do qualify and it is a covered surgery, you should be fine.

Good luck!!

I have BCBS of IL, but a different plan pays the bills (NEIHBP - national elevator health benefit plan), so I believe that may have made it easier for me. Just make sure you are vigilant with calling and clarifying with insurance what exactly you need to be submitting.  My plan required cardio/pulmonary clearance and I kept misunderstanding what they needed and had to keep resubmitting that info about 3-4 times, which ended up slowing me down about 2 weeks overall. Make sure that you are getting the records you need every time you go to a consult or to your PCP.  I had to have my PCPs office resend so much info to me because I kept not being clear with what I needed.  That slowed me down several weeks as well. I'm glad you have a supportive PCP, they are really helpful! 

Hi Kayla!

I see you are going to have the DS.  Does your plan cover it?  Were you approved the first time?  Just wondering what kind of a plan you have.  I'm getting ready to send in my appeal.  I'm hoping I'm sending enough info to them for them to approve THIS time!!

Good luck to you.

Mandy, Whenever I called my insurance before submitting, they didn't know what a DS was, so I couldn't be sure they covered it.  I just submitted and hoped for the best.  I got accepted on the first time, so I'm assuming my individual plan must cover it.  The NEIHBP part of the insurance, I think, is a big part of this reason.  NEIHBP pays all the of bills for the services, but they just pay a part of BCBS to have them do a lot of the paperwork and get a list of providers.  That is my general understanding of how my insurance works. My requirements were: BMI, physical, TSH test, cardio/pulmonary clearance, psych eval, 5 year diet history, weights for the last 5 years, and list of comorbidities. My comorbidities were: slight sleep apnea, high cholesterol, high triglycerides, stress incontinence, and mild skin darkening/rashes.  I also submitted records of my blood pressure (I had PCP office put it on the same paper as my weight history) for the last 5 years, showing that as my weight grew, my blood pressure started going up.  I have slightly high blood pressure. I hope this was helpful, you can pm me if you have anymore questions!

Hi Kayla.  Thanks for your response.  It sounds like your plan did cover the DS.  Or you would have been denied at least the first time.  That's great!  I was denied and had a peer review that upheld the denial.  I just sent off my appeal.  Keep your fingers crossed for me!  And good luck to you!

Hi Kimberleec! I also have BCBS of Illinois PPO. I have been denied  many times; however, not officially denied. They first requested more info. I sent it in and they said I didn't do the six-month diet (but I did). Then I resubmitted that and they said I didn't comply with the six-month diet. They didn't say why, but I assume that it's because I lost weight and then slowly gained it back. So, be on your toes! I've also heard other people say that they were denied because they lost too much weight! I had my dr's records and forms that I made myself each month and had my pcp to sign stating all that had been discussed at the appointment. I went into further detail on this form, but they said they wanted all of the information on the dr's notes. (go figure!) Also, be sure that you keep records yourself. Ask them to make copies for you to take home, as well. You can never have enough copies of your history! I pray that your approval goes quicker than mine.

Thanks everyone for your replies.  Your information is very much appreciated.  I wish you all luck and hope you are all approved soon and to those of you with a date and waiting for the surgery I wish you much success and good health. Thanks Kim