What does it take?

I presented my request for WLS in April to BCBS of IL. It included a 12 mo supervised diet w/ documentation of exercise (briefly) throughout the medical records from 2001-2002. BCBS of IL DENIED me stating that I did not have a 12 mo supervised diet. I hand-delivered my appeal to my employer in Illinois because it requires that under the ERISA plan. I was prepared to hire Gary because I have seen his many successes with winning. However I was advised against this because it might affect my new job which I took because it had insurance to cover WLS. Today I called to check on the status and I was told that they needed the 12 mo supervised diet in order to complete the appeal and make a decision. What does it take? I even typed up a spreadsheet showing each date during that 12 mo period that I went to the doctor. I entered in my weight and the reason for the visit on the spread sheet. I had medical records for everyone of these visits to correspond to what was on the spreadsheet. In addition, I had medical records included since 1993 on every diet I had been on. 95% of my medical records since 1993 was weight loss attempts. What does it take to get BCBS and the employers to READ the documentation? I told the lady at BCBS today that it will be an embarrassment to them when I take the next step in taking this to court and I go to present to the court that they had the 12 mo supervised diet all along. Do any of you have any words of advise? Because this is an ERISA plan, the Dept of Ins is not willing to do anything to intervene. HELP?!?!?! I have been fighting this for over a year and am not planning to give up. I just do not know what else they could want.

I was required to have a 6 mo MD supervised diet. I also submitted the paperwork to prove this. My insurance denied me saying I didn't have the MD supervised diet. 2 appeals later they said the same thing, no diet no surgery. Finally took a Judge to look at the papers and say, "Yes, you have a 6 month MD supervised diet" and ordered them to pay. It's crazy, I know, but the insurance wants you to give up so they can win, I.E. not pay anything.

I am wondering what the outcome of your appeal was. I also have BCBS of IL & your plight sounded very close to mine. In June, 2005 I submitted documentation since 1999, with two seperate 6 mo. Dr. supervised diets & with 2 co-morbidities & 5 yrs of exteme obesity documented, letter from my PCP. They took 12 weeks & denied, because I had not met the "medical criteria". Prior to this, I had gotten info from their customer service to know what I needed to send. When I got the denial, I went thru my HR dept & got a copy of the policy about gastric by-pass (abt 4 pgs). Then I could see that they wanted 12 consecutive months Dr supervised low-cal diet plan". I called for more clarification, & they said, when you go to the Dr. that must be the first thing on the visit notes & the first thing she codes on the bill (wt mgmt). & I asked about approved diet plans. "Weigh****chers, Jenny Craig, etc were on the "approved list", not just Opti-fast & Medi-fast. So I did that. I submitted 12 months of Dr. visits notes, another letter form my PCP, a "life graph" from Jenny Craig (which is all they would give me copies of-the mental & physical notes could not be given out), copies of the receipts for food I bought for 52 weeks. and sent it in again. Ten days of me calling them every other day & the first panel reviewed my latest documentation & denied me again. I lost 33 pounds over the first six months & slowly put that same 33 pounds back on the second six months. I ate their food & exercised & My body likes this weight!   Hell, if Jenny Craig had made me loose 66 pounds it just might make me decide that it was not worth it to do this change inside my body that will last the rest of my life! When it got denied, the girl asked me if I wanted it sent on to the appeal board?  Well, since that is where I had sent it this time in the 1st place I just wanted to scream-"Are you a total idiot?" but I did not, I just said yes, please. She said they try hard to get the appeals done in 60 days. SO I am on another WAIT. Needless to say, my life is hell right now & I am pulling hard away from my family & support, feeling defeated & worthless. Can you give me any hope??? Is there any possible light at the end of this tunnel???? Is a lawyer or the state insurance comissioner going to make any difference at this point???? The woman at HR at head-quarters told me that I might have followed all the steps correctly & they could still deny me. Is that true???? And No, there is no chance of self-pay & no other insurance possibility until next July. e-mail me at [email protected]