Need Advice on submitting to BCBSIL PPO

Hello all, I just had my last weigh in today, yes 6 months have gone by. Well the whole way I struggled to lose would gain a pound or 2 then lose that at one point gaining 5 pounds due to TOM. Well from my last weigh in to this one I have lost 10 pounds. Which only shows up as a 5 pound loss. I have worked to hard to get that 10 pounds off, barely eating anything. Following their 1200 calorie diet wouldnt budge the scale. Well they told me they could submit but I would most likely be denied by the insurance company. That I only get so many appeals, which I know. So I felt no way out and said I would go one more month, with the fact I could call and change my mind any time.  I talked to my sis in law who has gone through all this and she thinks I should have her submit. Thats what I was thinking, but was still not quite sure. The insurance company does not say any particular loss, just that it has to be 6 months of Dr supervised diet. What do you think?

I have the same insurance. i had my last visit last week and saw the nutr. for my eval on friday.I say u should submit. they can deny it and u can appeal it on the grounds that the policy does not states that any specified amount must be lost. You can still submit and try to lose at least you will already be started. then u can show that u tried an addtional month and it still didn't work.I am nervous too. i just got my medical report from 203 and it says i weigh 140. lol i haven't weighed that since i was 10yrs. old. i don't know what to do.I want to change it but i know that would be bad to do.i know that that is not the corect weight.i don't have the 5yr history they require but i will submit anyway.keep me posted.

If you have met all of their requirements, I think you should submit.  In the meantime, if you are worried about the diet not going through very well, I think you should continue your monthly appointments so that if they come back and say you have not lost enough weight, you will not have to start over again.

Hi,  I am finish with my supervised diet and today, I got a letter of support from my doctor. I need to make copies of all my medical records because some previous BCBSIL carriers have stated that the insurance reps sometimes claim to have lost or misplaced some documents. I am also writting a letter to plea for approval. I do not know if this will help but I am sending the documents this week to my surgeon's office.  Like many of you, I am nervous, anxious, and yes reluctant to send because I sometimes wonder if I a ready or not? What I mean by this is...how much will this impact my life and my new job? So good luck to everyone!!!By the way the insurance certificate I received from BCBS states "failure in 6 month supervised diet."

Hi Talia!

Yes, make copies of everything!!!  Its very common for your packet to get lost.  Better be safe than sorry.  Send them any relevant information.  Studies you have found showing how WLS saves lives, what your comorbidities will cause you in the future.... anything you can think of to plead your case.  Bombard them with paper!

I'm not sure what surgery you are requesting, but check out my profile if you have the time.  I have some appeal info there, as well as lots of documents on the DS and RNY.  If its the RNY you are going for, toward the bottom of my page in blue (look through the archives for all of it), there is a great letter to send your insurance requesting that.  You may have to reword things here and there, but its packed full of great information that will show your insurance company you know what you're doing and show them how well informed you are.

Good luck to us all!! 

Hi Mandy, Thanks, and yes I am seeking RNY. I have been saving lots of data on the procedure and new studies regarding the surgery to help my case. I am hoping I can just sit down this week and just complete the letter so I can at least finish my part in the process.  I am hoping my surgeon's office do not take  a lot of time submitting. I want to hand deliver the documents so I can ensure they received it. The office is 45 min away from my house. Anyway, I am hoping to complete my part this week like I mentioned.

Sounds like you are all set then.  I know what you mean, though, about wondering wether or not you are really ready to do this.  It's like, you get all caught up the insurance hoops and making sure you've done everything just right.  Then after it gets sent off, you sit and think, okay, is this really what I want to do?  Did I really try as hard as I can on my own?  Will I be a success story? 

My insurance office took forever to submit.  This whole process has taken forever.  I started my 6 month diet back in October last year.  Hand delivering is the best way to ensure it gets there without a hangup.  I had a cd of an upper gi I had done that I had to send 3 times to my surgeon's office!  OY!  If nothing else, this whole process teaches us more patience, right?

I'm hoping for the best for you!!

Hi Talia,
I am submitting this month too.I am also going to write a letter. did you meet all the other requirements?

Yes,  I have completed all the requirements. I have not lost weight but I have not gained weight either. That is the only thing I am worried about. Are you submitting directly to the insurance company or doctor office? I am submitting to my doctor first then I must wait for them to submit to the insurance company.

SUBMIT!!!  If you have indeed completed the 6 month diet, then you have accomplished what they asked of you.  Like Kayla said, I would continue to go monthly if you feel they may say you need a few more months or even to start all over for some reason.  Nowhere in my policy (Highmark BCBS of IL PPO) does it say you have to be successful on the 6 month diet.  That's a little crazy.  If we were so successful at dieting, we wouldn't need WLS, would we? 

Copy your entire packet that you send them.  They may give you the runaround and say they haven't received anything.  I even sent my appeal and paid extra for a tracking and signature confirmation so they couldn't do this to me.  But stay well armed and they will know you will be one of the ones that aren't going away.  It's very common to be denied.  If you are, don't sweat it.  Appeal and you will get your surgery.