Denied BCBSIL Lame excuse

Well BCBSIL strikes again! I was denied my surgery with the reasoning my dietician who is affiliated with the surgeons office only had me on a 1200 calorie diet. According to BCBSIL that is much too high it should be a very low calorie diet of 800-1000 calories. Now no where in their requirements does it say a certain amount of calories. I asked is this the reason you are putting on the denial, they said yes. I swear first the run around, and now this. Last time it was I would be approved, words of the ins. rep if I got the letter from my Dr stating my weights for 5 years and that they would put me at MO, with him signing it. I got it faxed to them, and now instead of an approval, they pull this crap out of their hats. Give me a break, I can't believe these people.

Renee -    Sorry to hear about your troubles. It is amazing how they do come up with different requirements as the process goes along. Request a copy of your "Explanation of Benefits", this is where everything should be stated. I'm requesting mine on Monday, I too am getting tired of the "run around"! Hang in there and keep trying!

Renee, you know what I say! Appeal. See if anyone can advise you of how to do this b/c it said physician supervised not 1000 cal diet. I am really getting sick and tired of them! But we cant let them win!!!!!

Ah, good ole BCBS of IL!!  They just have to find a reason to deny, don't they?  Ask them to send you the requirements for wls and an explanation of why you were denied.  If it does not say anywhere it has to be a 800-1000 calorie diet and that's why they denied you, you send them their paperwork back and tell them you are appealing their denial.  It will take another 30 days probably.  Will your surgeon's office go to bat for you?  It's their cost control tactic to get you to give up.  DON'T!!!  If you have jumped through all of their hoops, they have to approve you.  Good luck!

Renee, I am so sorry to hear about your denial. I just don't understand how they can deny you for a 1200 cal diet, when their policy does not specify the # of calories you should have in a day. Plus, your doctor is obviously a much better judge of how many calories you should be consuming...not some guy in a suit behind a desk pushing paper!! Don't give up!!! APPEAL!!! From my understanding, an appeal goes to a different area in the insurance company and will be reviewed by a panel. You should also check to see if they have someone that can review your case that is knowledgeable, such as another bariatric surgeon unaffiliated with your chosen surgeon. I really wish you the best...keep fighting!!!

LAME INDEED. First, there is no "standard" caloric intake. Doc and nutritionalist have determined what is right for YOU. People have different metabolisms, and some people require MORE food to keep from going into starvation mode where they store everything as fat instead of burning it. My metabolism is so messed up, my nutr gave me a 2,000 calorie diet after taking a metabolism diagnostic test, and determined I was eating too LITTLE. You also have a potential grievance. Insurance is NOT allowed to dictate medical care. They are not treating you, and it is probably just some nurse looking doing her job of finding a BS reason to deny. Also there is nothing in the policy that states you have to be on a "very low calorie diet"-- just a "diet". That very low cal diet isn;t even healthy for most and can put many people into starvation mode and actually SLOW down the metabolism! You can file a grievance with the state's insurance governing agency/commission. At least call and ask them if it is legal for them to do that. If you file a greivance, and they investigate, they may throw out that denial. See you only get 2 appeals, and you shouldn't have to waist one of them on something so unethical and illegal. They would have to redo the review of your initial request without using the caloric intake of your diet, and they may have no choice but to approve it.  Good luck, Kahlua