Blue Cross Blue Shield of Illinois

Blue Cross Blue Shield of Illinois, Can someone give me the stats on that please ? Like requirements, and if you had a easy or hard time with them thanks

-Kim

I have BCBSIL here is what their requirments are:

To be considered eligible for benefit coverage of bariatric surgery for treatment of morbid obesity, the following three criteria must be met:

A. A diagnosis of Morbid Obesity, defined as:

• Body Mass Index (BMI) of greater than or equal to 40 kg/meter squared; OR
• BMI greater than or equal to 35kg/meters squared with at least two (2) of the following co-morbid conditions which have not responded to maximum medical management and which are generally expected to be reversed or improved by bariatric treatment:

1. Hypertension,
2. Dyslipidemia,
3. Diabetes Mellitus,
4. Coronary heart disease, and/or
5. Sleep apnea.

AND

B. At least a five-year history of Morbid Obesity supported by medical record documentation.

AND

C. It is expected that appropriate non-surgical treatment should have been attempted prior to surgical treatment of obesity.

Non-surgical treatment of morbid obesity appropriateness criteria:

• Medical record documentation of active participation in a clinically-supervised, non-surgical program of weight reduction for at least 6 months, occurring within the twenty-four (24) months prior to the proposed surgery and preferably unaffiliated with the bariatric surgery program. NOTE: The initial BMI at the beginning of a weight reduction program will be the “qualifying” BMI used to meet the BMI criteria for the definition of morbid obesity used in this policy.
• A program will be considered appropriate if it includes the following components:

1. Nutritional therapy, which may include medical nutrition therapy such as a very low calorie diet such as MediFast or OptiFast OR a recognized commercial diet-based weight loss program such as Weigh****chers, Jenny Craig, etc.
2. Behavior modification or behavioral health interventions.
3. Counseling and instruction on exercise and increased physical activity.
4. Pharmacologic therapy (as appropriate).
5. Ongoing support for lifestyle changes to make and maintain appropriate choices that will reduce health risk factors and improve overall health.

I am still in the approval process.  It is has been a little journey.  One recomendation is when you do the six month physisian assited diet, get a nutritional consults as well.  I truned my stuff in and the insurance company requested a nutritional consult.  Luckily for me I was just diagnosed Type II diabetic and was in diabetis education wi*****luded a nut consultation with a registered diatitian.  Also, they requested a cardio clearence and pulmonary cleareance due to history of cardiomypathy and asthma.  I got those and they were turned in on Tuesday.  So hopefully I will hear somthing soon and they will not put it off anymore.

I was denied on Feb 26 by BCBS of IL for the lap band.  I have met all of the requirements.  My surgeon's office sent my file to Obesity Law because no one can figure out why I was denied.  In the denial letter it states that I did not attempt pharmalogical means for wt loss.  That does not make since.  I did Weigh****chers for 8 months and lost 56lbs. The policy does not state you have to take medication for wt loss also. Good Luck to you!

The only problem I have run into with them is the 6 month diet not being 180 days long. I have had several patients denied because of this. Not only do you need 6 monthly visits, you have to pay very close attention to the dates to make sure it's 180 days. If you begin you 6 months at the end of the month and end at the beginning (because we are all anxious to have surgery) you will be very short on days. Sometimes when I have calculated it out it was 138 days, (which is technically only 4.5 months). SO BE AWARE! Use timeanddate.com to calculate your beginning and end dates, add on a 7th visit if needed.It really sucks to wait 30 days with BCBS IL to deny you for being 20 days short on your MSD! Good luck! Bonnie

thanks for all your comments..it seems like bcbs of il is a tough insurance to handle

i have bcbs/il . i was denied at first for not having 6 mnth die. I did though. so sent it back in. then they said i didn't have a psych eval i did! then finally they said i did not have the 5 yr history. i only had 3 yrs. so i went back to 1997 sent that in and was APPROVED. don't give up. if you need more help let me now.

Thanks!