BCBS of Il-denial twice

I recieved the letter today saying I was denied becase I don't have a 12 mos supervised diet however I meet all other criteria. What gets me is this. When I first submitted the criteria said nothing of a supervised diet. I read it twice then made my husband read it. I was denied the first time for not medically necessary in which in the denial they spelled gastric wrong. Come to find out, BCBS of Il changed their morbid obesity policy in April of this year without so much of a warning. So reading the letter today I noticed that they didn't copy in all of my doctors and clearly didn't read all the notes because it said a psyc eval was not referenced. On pages 45-47 it was there in black and white. I couldn't believe it. I have already submitted a claim to the insurance commisioner in Il and have called the nurse who signed the denial to see if they would relook at my information and also I want to get the credentials of the surgeon *****viewed it. I am about ready to drive down there and pitch a tent in front of the building until they approve me. Any suggestions. Cherie

BCBS of ILL is also messing with me. I'm fighting them with Gary, the lawyer as it's not fair. Donna

You need to file an appeal, and follow the appeal procedures in your denial letter. Don't ask them to just review the same information again. It is quite possible that some info has been lost or tragically "misplaced." The 12 month diet is an obvious stall tactic. Request a copy of their utilization review guidelines, and the basis for the guidelines. Be sure to FEDEX or UPS everything. Make a list of all attachments, and put it on your appeal. Fight the good fight! Roberta

Hi Roberta- I was just denied by BCBS IL because they claim I did not provide enough information on the medically supervised weight loss for 12 months. I sent in approximately 3 years worth of medical records, with an itemized spreadsheet, detailing what I have been doing for the last three years. Anyway, that being said...My question is do you have an example of an appeal letter and other items I may include in my appeal? I am desparate and really don't want to self pay. Any assistance would be appreciated! Thanks! Heather

Heather, I write appeal letters for a living (I'm a Patient Advocate) so I can't "share" my work product with you. However, if you have any specific questions, I'll be more than happy to answer them for you. I would suggest that you go back through your medical records, and take notes on each and every date where diet or exercise was mentioned. You will want to highlight those visits in your appeal. Also, read my Do's and Don'ts list. I posted it a few weeks ago. If I can help in any other way, please feel free to email me. Fight the good fight. Roberta

Hi Roberta- Thanks for the response. I apologize as I did not realize you were a Patient Advocate! The problem is that on certain visits there is mention of what I was doing and others all the doc stated was 'very concerned about weight gain'. I put together a document which detailed from 2001-2004, what I have been doing and who was supervising. I attached all the docs notes going back. They are saying that is not enough. I will check your do's and don'ts. I remember reading them and they were very helpful! Thanks so much for your time! Heather

... I called BCBS and told them that I had spoken to our legal department at my work and according to our contract with them they have to notify us either by individual or company when a policy change takes effect no matter what it is. I called the nurse back who's name was on my appeal and told her this and also told her I don't think all my material was recviewed. She asked me to fax my pych eval and any additional medical records including a copy of the 8-15-03 policy. She said she would have it reprocessed under the prior years policy. I know I haven't been dealing with this as long as some others, but it feels like it is taking forever. I did update the Illinois dept of insurance as well. Thank you Roberta A for the great suggestions on the Do's and Don'ts of the appeal. There were a few things in there I had never thought of. I am hoping this time will be the trick otherwise you might see me on the news in my tent. Thanks again Cher