BCBS of Illinois / Employer

I received my letter from my employer this evening. They agree with BCBS and denied my request to have the gastric bypass surgery. Reason being that my 12 month failed diet was completed in 2001-2002 and they require it to be covered the the past 24 months. It was my prayer that I not be approved for this surgery if it was not God's will for me right now. If it is not in His timing, I do not want it. God has answered and I will accept his answer. I know that He heard all of your prayers and this is the right thing for me right now. Fortunately, I am on my seventh month of a current 12 month diet and in January I can submit this to BCBS again. Beth M

Beth, I am so sorry that they denied you. I know this is a really hard time for you, but you are 1/2 way there to the 12 month diet!!! Keep your chin up and have faith. It will work out for you. Keep in touch and you are always in my prayers!! Lots of Hugs!! Jen

Good attidute to have Beth Keep doing what your doing and you'll be blessed with your surgery. I had to go through the same process and the waiting was worth it I had my days of crying and thinking I'll die being obese but I hung in there until I got the approval letter. Now I'm fighting to get the SOB's to pay my surgeon Donna 338/193

Honey do not sit around waiting for god to step in! Do the research and take control yourself! I have BCBS of Illinois and they paid for me. My surgery was July 7. A diet attempt older than 24 months will NOT be accepted. That should be common knowledge around here. That's pretty standard. God has nothing to do with it! First of all, I have a copy of BCBS's official criteria for approval. I will look around for your email and send you a copy. I printed it out and took it to my doctor. We went over it together and devised our plan. My doctor wrote another letter at that time. She wrote very strongly against how BCBS wants you to be practically at death's door before they say they will approve. She insisted that as my physician she would not allow me to reach that point. Co-morbidities are absolutely critical. You MUST have at least TWO. My doctor had me on meds for cholesterol, blood pressure, and blood sugar. THREE of BCBS's required co-morbidities. I was very close to turning full-blown diabetic and that's what we pushed HARD to BCBS. I began seeing my doctor last May for monthly weigh-ins. She made notes every month. But if you read BCBS's requirements, they ask for a nearly impossible regimen of dieting (including a medical fast), medication, supervised exercise, behavioral modification, and psychological therapy. They will look for ways to deny you on the 12-month diet so don't pin your hopes on it. Be able to say you did it but YOU have to make it secondary to more important issues by focusing on your co-morbidities. After I was denied the first time, I wrote a two-page appeal letter. Nobody is going to read 240 pages and it won't be god's fault. I focused on how I was nearly diabetic and how my blood pressure could only be controlled by medication. Mostly, I pounded away at the dieting requirement. I pointed out that my doctor provided documentation of my obesity for the 15 years I was her patient and how I followed every weight loss recommendation she had made. I argued that denying me surgery based on a dieting requirement was tantamount to denying treatment to a lung cancer victim for failing to quit smoking. I also argued hard that it was inevitable that I would turn diabetic and my health care would cost a great deal more in the long-term. I cited a statistic I got from an issue of JAMA that WLS pays for itself in health care savings in about two and a half years. Expenses for me as a diabetic would go on for the rest of my life. The best break I got was when my case was sent for review to a third-party reviewer. A bariatric surgeon in Boston called my doctor and they discussed my case at length. The surgeon-reviewer recommended surgery for me to BCBS and I was approved. The woman at BCBS who was responsible for sending my case to a third-party reviewer was Kathy Patrick at the 300 East Randolph office. Write to her and ask for a third party reviewer but HAVE YOUR PLAN IN PLACE. Don't go to battle with BCBS without being prepared with information to fight! Personally I think the worst thing working against you might be the fact that you admitted you once lost 77 pounds on your own. They will probably feel that you can do it again and will expect you to try! I had no significant weight loss in my past. If your insurance is employer-funded you will have to work with your employer on this. A friend of mine went through that. He worked for Papa John's Pizza in regional management. I guess they felt a huge fat guy didn't present a good image for a restaurant. Make a case for what would matter to your employer. Do you deal with the public or clients? Does your job require something of you physically, such as, do you travel and work long, busy days that wear you out and you are not at your best? What will your co-morbidities cost the company in the long-term? It must make sense to them in terms of MONEY. They care more about money than you. That's reality. Take control of this YOURSELF! There's a lot you can do but be prepared to deal with the REALITIES of what ALL the insurance companies are doing!

Dona, Thank you for your comments. I have been working hard towards getting approved and having just getting this insurance company in January, I immediately started taking care of the criteria that BCBS of IL and my employer (ERISA) had listed. Please know that I have worked very hard to get approved. My 240 pages were medical records and not an appeal letter. It was what my employer required to review in the formal appeal stage. I do not blame my denial on God - but I give him the credit for what he has done and his timing. Thanks for offering the criteria. I have it from the bcbsil.com/medpolicy.

You called the "240+" pages an "appeal document." I have described to you what ACTUALLY WORKED for me with BCBS-IL. Keep waiting for "his timing" if you want.