What BCBS of IL really means......

I made the call today to BCBS of IL to ask them what they are asking for in the 12 mo supervised diet. Many of you with this insurance have read the policy and know what I am talking about. The policy reads... "A documented failure of twelve (12) continuous months of compliance with medically supervised non-surgical methods of weight reduction. Medical supervision must occur under an MD, DO, or nurse practitioner within the previous 24 month period prior to the request. . A medically supervised weight management program is expected to consist of: Nutritional therapy or medical nutrition therapy including a very low calorie diet (e.g., MediFast or OptiFast) unless contraindicated., Behavior modification or behavioral health interventions, Supervised increase in activity, Pharmacologic therapy (unless contraindicated), Maintenance support to continue to encourage nutrition choices to reduce health risk factors and maintain a healthy lifestyle. "[taken from bcbsil.com/medpolicy] Today after talking to Alisha, she advised that the medical records that I submitted from my doctor were not good enough.... what they need are: - each visit separated on a separate sheet -the beginning and ending date -any diets and exercise within that period -any lifestyle changes within that period -and progress notes Apparently the information that my doctor had put in my medical records that were on separate sheets was not detailed enough for them. Not only that, they should list this information in the medical policy to give their members a better idea of what they do expect instead of wasting their time. Nonetheless, I felt that this information might help out just one person so I thought I would share it. Good luck! Beth M

BBS of IL is a JOKE!! I had them and they will jerk you around and around every time you call them. I got so sick of that insurance company but in the end we won Sadly I might have to go back on my husbands insurance in 2006 Donna 338/204 -134

How? Any tips?

I have Horizon NJ Plus. My revision was denied. I think in error. I am mailing my appeal tomorrow. I have a host of medical problems. They said it was not medically necessary because my BMI was 35 and when I had the original surgery it was 54. My experience is they automatically deny you because they don't think you will fight. I filed a complaint with the Banking and Insurance Commission in NJ which they don't like.

They first told me 6 months of dieting, then threw a loop hole in there stating they changed it to a year of dieting. Everytime I called to check on my appeal it was sent to the legal dept. which it should not have been sent. The refused to listen to me when telling them that it's an APPEAL, not a LEGAL MATTER!! They drug us threw the mud and I don't think it's because they wanted to as much as NOBODY knows what they are doing or talking about when you call BCBS of IL. Make sure you document EVERYTHING when you call. Dates, times and who you spoke to. Donna 338/204 -134

Hi Beth! I see you're still battling with them too! I got my second denial letter from them this week, but to be truthful, I have not completed the one year's "failure." What concerns me is that when I do complete it, they'll pick that apart and deny me again! What you say about a separate sheet is the first time I've heard that. I am going to see my doctor once a month and he is documenting everything, but I know that'll not be good enough for this $%^&* insurance company. I reqally think they figure if they put us off long enough we'll give up or die and they get to keep their money and continue to take the premiums each and every month!

I did the year of dieting and then they approved me. Get everything down in writing on what your doing with your diet and have every Doctor write letters to your surgeon to submit it along with his paper work stating that you MUST have WLS. Good luck Donna 338/204 -134

Yes this insurance co does really suck. I live in iowa but my employers main offic is in il. so we have bcbs of il. I have tried everything under the sun for them to approve me. But i guess my doc did not document enough!! so I am self paying and going to Mexico. I am fed up with the health care system here!! It is bad enough we have battled the weight problem for this long and now we have to battle the ins co. I am tired of fighting. Even the people at obesitylaw.com told me that they have about 30 cases against bcbs of il that they are fighting and have been for the last year!! No hope in site!!! Good luck to everyone!!

I wanted to reply in the hope that you or anyone else unfortunate enough to have this insurance will not let them discourage you and give up the fight. You deserve a better quality of life. I did not go into much detail on my profile so I will explain further. My first paperwork was submitted September 20 2004. This included 18 months documentation of diet attempts including Weigh****chers, Atkins, and perscribing Meridia for two months. These were not "consecutive" but continuous with some lapses of 2 to 6 months. I did not see a Dietition or join a Health Club, but It did mention in the Dr.'s notes that I had a tredmill and was exercising 3x a week. During that time I had lost 83 pounds on WW but gained back 60#. Also submitted was the required psyc evaluation and letter from surgeon including CPT code and explanation of procedure. I called at the end of the week to follow up and BCBS of IL said that the surgeon had requested a non-covered procedure. After almost having to give the customer service rep the 3rd degree, she gave in and explained that it was a clerical error. I contacted the clinic's insurance dept. and they said they would re-submit it. Then, on Oct 13 got a letter from BCBS of IL saying that they needed more info. I called again to inquire and they said that they had no info from my PCP. 19 pages lost?, I think not! Just a way to jerk me around and stall. Once again the entire packet was re-submitted. Nov. 11 got the formal denial letter citing no 12 month supervised diet attempt including nutritional therapy and increased exercise. After that I spent a month on this site weighing my next option and getting advice from my knowledgable and experienced peers. I decided to hire Gary Viscio because my experience with BCBS of IL so far was nothing short of a circle jerk and I wanted them to know I ment business. I didn't hire him until the end of Feb. 2005 though, because of my having 4 kids and Chistmas expenses. Not to my suprise, things seem to roll along quickly after my appeal was subbmitted April 1st 2005. Thanks to Gary I recieved my reversal of denial May 12 2005 and am now starting my renewed healthy life. BCBS of IL is a nightmare and will do anything they can to get out of paying for this surgery, but once they are called out they know that their vague policy cannot stand. Keep fighting! You can win. The best of luck to you.

Thanks for posting this! I started my 12-month diet history thing last August. I am only a few weeks away from submitting all the paperwork and referral from my PCP. Hopefully they will come through for me. If not... I will keep fighting. I'm young, so they can expect me to be complaining for a LONG time.