BCBS/ ILLINOIS Denied based on no documentation of 12 mo WL failure

Hi Everyone: I just got the news that I have been denied based on no documentation of 12 continuous months of weight loss failure. I have been seeing my PCP for over three years, weight issues on and off during that time and a course of 9 months on Meridia with no significant WL. The lady at BC/BS-IL said I had to have documentation thatI was in there EVERY MONTH! I was not there every month and my Dr. didn't require me to be. I am going to see if my PCP can send in yet another letter, and more documentation. Think there's any hope for me getting this overturned? It seems to be a common problem for so many of us. I am so confused over the wording in my polity over what they want, to me it seems vague and as if they can bend it any way they want to keep denying you. Any advice or help would be truly appreciated. Cindy

I also have BCBS of IL and was denied for the same reason. You're right, it is vague and that is a key point in appealing that denial. Somewhere on this site I know there are sample appeal letters that have reversed deniels. Im sorry I don't know the link, but if you post for it I'm sure someone will share it with you. I employed the help of Gary Viscio to appeal at a very reasonable fee and I got the approval last Tuesday. I did not see my PCP every month, more like every 2, 3, and even a 6 month lapse in my documentation of 18 months. Please don't give up! they are hoping you will go away and the documentation is their way of trying to weasel out of paying. Good luck to you. I hope my reply has given you encouragement.

I have BCBS/ MN. I met with a dietician in March, who told me to come back in 3 months. I called my insurance company at least 4-5 times and asked different customer service representatives if every three months was ok for the needed documentation for WLS. All of them said to follow doctors orders, they can not tell somebody to do different than the Dr. advises. Hope everything works out for you.

Hi Cindy, I am in the same boat. I have lots of medical documentation - including four months years ago on Xenical. They just want to put us off. Not sure what advise to give, I am looking for some myself. I am seriously thinking of hiring Gary, but $$ is a little tight at the moment. I also hate to try and do it on my own and lose the appeal - I was told I only get ONE. :o( Cindy K