NEED ADVICE AND HELP ON BLUE CROSS NEW RULES

I am one of those badly in need of this surgery (BMI 50, Diabetes, Neuropathy, high B/P, apnea. etc) that got caught in the Alabama BC/BS 11/29/04 hiatus on approvals, after which rules were drastically changed and approval rate went through the floor. My MD expected easy approval, now I'm facing that "6 months medically supervised diet" (the documentation of which may or may not meet their criteria- I hear it's a turkey shoot), and all the rumors that MANY co-morbities must be present. Also have been told that, since present experience with the new rules is limited, doctors do not yet know what oddities of requirements may yet come up. Have any of you had experience (appeals, special cir****tances, assistance from your MD, special recommendations to follow to meet guidelines, experience in later denials, information as to interpretation of these confusing rules etc.)? ANY advice that might help me deal with this situation would be appreciated? THANKS FOR ANY HELP! Julie

Have your surgeon submit for pre-approval. If you are denied, you have the right to request a copy of your file with all of the information used in denying the request, including the utilization review criteria, and all scientific evidence used. Then you will know exactly what they are looking for in the approval process. However, I would have your PCP document your diabetes and neuropathy clearly. All of the newest medical published shows that WLS cures Diabetes (type 2) in 77% of patients. If you are insulin dependent, I would strongly insist that this surgery is medically necessary, especially if your diabetes is not controlled. Fight the good fight! Roberta

The 6 months supervised diet has criteria: Your PCP must document that he/she is placing you on a supervised diet, what it is and what they expect. They should also include in their notes about your comorbilities and that you are interested in RNY. It must have your weight and height on every visit note. You must go each month and SEE your PCP; you can not call in your weight or just be weighed. You must physicically see your PCP, basic workup (height, weight, blood pressure). If you're down a pound(s)-good; if you did not lose, then he/she is supposed to document their recommendations to adjust or follow in your prescribed diet. I'm going thru the same darn thing. My PCP place me on a diet 18 months ago--I've lost and regained the same 20 pounds all year--my yoyo 20. However, because he did not document the "supervised diet", and I did not physically SEE him each month (because my insurance didn't cover that), it's not 6 months of documented supervised diet. I'm still pushing it. Also, check with your local office for Alabama Vocational Rehabilitation Services. Sometimes, with comorbilities, they will pay for medical procedures that would either prevent you from becomming unable to work or enable you to rejoin the working force. I've requested my appointment with AVRS and I'm waiting on my letter for them. You'll have to give them copies of your medical records as well. Anything is worth a shot. YOU are your best advocate. I waited on my former surgeon's office to submit paperwork and they dragged their feet so long that my contract ran out before I was approved. I paid them alot of money upfront for consultation and pylori screening--never to be reimbursed. Because I saw them, it got caught up in a pre-existing clause and I was held up for 2 years. If someone had told me about AVRS, I would have applied for it then. To think I would be so much healthier now and my heart would not have gone thru the last 24 months of stress, kinda makes me mad. Good Luck and DONT GIVE UP! Alli in Alabama

Hi Allison! I just read your post and I was curious about what you said about Vocational Rehabilitation paying/assisting with WLS due to co morbidities. Can you give me anymore information about this service? I live in TN but we also have a Vocational Rehabilitation office. What are their qualifications for service? Do you know if it is income based? Do you know if qualified, if they will pay for the WLS in full? Please respond because my insurance (BCBS of TN, PPO) has an exclusion for WLS and I desparately need this surgery (I have a BMI of 64.9 with several co morbidties). However, I am working F/T, will that count against me? I look forward to hearing from you. Feel free to email me if you'd like. Thanks, Tammy

Hi Julie, I have the same insurance as you. I was denied, I appealed and lost due to lack of documentation and they wanted a 6 month supervised diet with a MD. I am on my 4 month now and no weight lost. I am not sure this is going to work either but we will resubmit in July. My husbands company has to resign contract with bcbs in August and they could not carry this surgery at all then! Also, another company my husband may go with is bcbs of Miss. and they do not cover it at all! So, I am praying to get it done with Alabama before any changes! Good luck! Karen