BCBSIL -- UGH!!

I received a denial letter recently for RNY from BCBSIL PPO because they state that I did not meet the 6 month medically supervised diet plan. However, I have met all of the requirements that are outlined in their policy. I reviewed my documentation from the APN, dietitian and PT trainer that I have meet with at least monthly since April, and believe that their documentation meets their policy requirements, whi*****lude (I'm paraphrasing here): 1. Nutrition program involving a very low calorie diet OR commercially available program such as Wg****chers, Jenny Craig, etc...

2. Increased physical activity

3. Behavior Modification

4. Pharmacologic treatment (as appropriate)

5. Adequate support systems to follow the bariatric program requirements. The insurance person today told me that they have these problems: 1. They don't see that I followed a very low calorie diet.  I followed Wg****chers, which comes out to about 2000 calories for my weight and should be accepted according to their policy. Very Low calorie diets are around 1200 cal which is too low for my BMR 2. They state that the documentation of physical activity is vague, although from what I have read in my chart it's pretty specific. The dietitian and APN both documented what I was doing (for example, 3X/wk, 30-45 min) and we submitted progress reports from the physical therapist / trainer. 3. They said that there was no documentation that I followed their directions. Although the notes frequently refer to whether I'm following the diet, exercise plan and medication I was taking. This is frustrating, because either they just outright deny everything the first time they see it, or just didn't read the records. I'm planning to submit a letter from the APN outlining how I have met the criteria, along with attendance records from the physical therapist and some information from weigh****chers which shows how many calories/points they recommend for weight loss for my weight category. Has anyone else had these same issues with BCBS and how did you resolve them?? Thanks in advance for your help.

All I can say is don't give UP!  Appeal, Appeal, Appeal.  Prove that you have submitted everything that was required.... Call them too...... Keep at them! kerri

Thanks for the encouragement Kerri. I  think this is just standard practice on their part unfortunately, but I don't plan to give up without a fight. Still hoping for surgery sometime in Nov or very early Dec.

I agree with Kerri! Appeal appeal appeal!!! They are sitting there with a deny stamp and without even evaluating documentation, they stamp it. I am dealing with the same insurance and was also denied despite the fact that I followed everything as well. What do they mean no documentation that you followed their directions? Are they suppose to follow you around and watch what you do??? I mean thats what the progress notes and things are for!  They are trained to deny no matter what and hope that we give up after the first denial.  A lot of times we do give up which is what they are hoping for. I sometimes feel like quitting because it seems as if its hopeless. Just keep calling and sending in paperwork. Call until someone there gets you some definite answers.  This is something you cant give up on. Do what you have to do and never let down! They will see you are serious! When you call and dont like the responce you get from one of the reps, call again! Be sure to update and let us know what happens! Good luck and I will add you to my prayer list of many others dealing with insurance issues. Tamika 

Thanks Tamika. I have had many thoughts this week about quitting this process and just going back to the same old diet/exercise plan that hasn't worked 1000 times before, but am trying to remain positive. It's hard since I've given alot of time and effort to this and I know that this is the right thing for me. Of course, I'm sure that's how you and everyone else feels as well.  I don't know what to say about the documentation that I followed their directions. One month it says that my goal is to keep food records, then the next month it's documented that I kept the records and turned them in. It would take an idiot to not understand that that means I followed their directions. The same things were documented about physical activity, and other things. I agree with you that they are probably trained just to deny up front and sort out those who are committed and those who aren't. I've called the insurance company every day this week, so hopefully they're getting tired of hearing from me!! :) I plan to keep going until I have exhausted all appeals. I really don't think it will come to that, and am praying that my surgery date will come soon. Good luck in your battle...and I hope your date comes soon also!!

Insurance SUCKS!!   My surgeons office just called me yesterday to let me know they faxed all my stuff in to BC/BS of IL......so I am impatiently waiting.  Do you know how long it took to get your response?  I am keeping everything I got crossed if hopes of approval.  But I am sure, like you I will get the "standard denial".  APPEAL!  APPEAL!  APPEAL!!!!! I will keep you in my thoughts!!!

My stuff was submitted around 10/4 or 10/5 and I was initially told it would be up to 15 days. I got my denial letter in the mail on 10/14. It didn't take them long...I'm sure because they didn't really look at what was submitted. If you get the denial letter....call and make sure they tell you what the real issues are. The letter is just standard and doesn't tell you much about what they take issue with. I agree that they SUCK!! I just wish we didn't have to rely on them so much. Good luck to you!! I hope you get good news soon.

Hi. I, too, have BCBS of IL and was denied over and over for simple little stupid reasons! I did all of the right things, but they nit-picked until they could find any little thing to deny me. I am sorry that I don't have any advice,  but I just think you should keep trying. I called everyday, at least one time. It didn't help, but it kept me informed of what was going on with my case. The last thing they said was that I didn't comply with the diet....didn't lose enough weight, so I'm continuing on with my diet. I started my six-month diet in March, so I now have 8 months of supervised diet. I know that I didn't lose much, but my friend, who went to the same dr and lost the same thing and had the same ins. as I have, got approved! Go figure. Who knows? I think you just have to keep on and on and on. I hope you find out what happened. Usually you can find someone nice and get their ext #. From then on, I would talk only to that person and keep track of who it is and when you speak with them. Don't let them deny you without a fight!!! Karen

Well I have been dealing with BCBSIL for weeks now. Each time I call and I did get a very nice guy and his extention, they come up with another reason to not approve. Each time I made sure they got what they said they did not have. Now they told me I needed something from my PCP stating I was MO and that would be the last thing. NOT! Now I am told that my dietician put me on a 1200 calorie diet and that it would not be low enough. That unless I could get something from them stating I am on something between 800-1000 calories I will have to start my 6 month diet over. Now I know 6 months isn't a long time, but still I know they are just giving me the run around. He said oh just think by next April you will be done with the 6 month diet. I am ready to be done with it now, not in April. I think I am going to call BCBSIL and speak to a supervisor, something smells I followed all their criteria and still getting the run around.

Renee - what type of diet did you follow during your 6 month diet? Were you on a program like Wg****chers or Jenny Craig? Or did the dietitian put you on a certain # of calories? BCBS policy says you must follow a very low calorie diet OR a commercially available program such as WW or Jenny Craig. I did WW, so I'm hoping they'll honor their policy, but I'm getting really worried about this.

The APN/dietitian I worked with are writing a letter, and I'm sending a letter from my PCP along with information from Wg****chers that shows how many calories/points they recommend for my weight. I really hope this works!!