BCBS/NJ anyone?

Hi, I am wondering if anyone out there has gone through them? I have been at this for a year now and now I am again in the waiting process.

I have thyroid issues, my BMI is about 50.  I fluctuate those 5 lbs back and forth between 48 and 50.  I am borderline diabetic.  I am treating with diet and exercise,  (which is soo much fun with the arthritis and all that weight on my knees and ankles)  I also use a CPAP Machine b/c of apnea.

I am miserable right now.  I am trying so hard to stay up beat but right now its getting harder and the pessimisim is starting to win out.  I just updated my profile with info from today also.

 

Any thoughts on time line or really anything are much appreciated.

THANKS  

Vicki, I have BCBS NJ PPO  I went through the approval process last year about this time. At that time they required a psych consult, a nutrition consult, a 5 year weight history (and although they don't tell you this, your BMI for those five years needs to be at least 35 or above) At the time, they did not require a 6 mos supervised diet.  I don't know if they now do or not. I was approved by them on the first shot - I also had my primary doctor send a letter of support with my application.  It included all the info they wanted (from the right doctors, like the psych and the nut), my five year weights, diets tried and failed, co morbid factors, and medical reasons surgery would be beneficial to me. I believe if your BMI is 50 or over AT THE TIME of application, they will refuse to because a BMI of 50 or greater is "considered experimental" so more red tape.  So, try to have your last weight at that 48 or 49 mark and have your doctor state "The patient is so and so feet tall, weighing so and so pounds with a BMI of so and so"  I don't think it matters if at some point before this your BMI was 50 or more. Best of luck Pam

I also have Horizon BCBS ppo.  Its called Horizon Direct Access.

I have done the psych eval, the 5 year weight history (went from 175 in 99 to 300 in 07) I have also done nutritional consult.  I submitted my paperwork, or actually Barix Clinics did and I was denied.  :(            So I get my paperwork in and it says I was denied b/c I didn't do a 6 month thing with my doctor and didn't have co-morbidities.  As far as I know Sleep Apnea is a co-morb. I have done everything I can thing of, you name the gym I have been there, you name the diet I have tried it, you name the pills I have tried them!  I broke my left leg, and by broke I mean shattered my tib/fib back in Oct of 03. And my bones will never heal properly so I have a rod and some screws in there and there is only so much exercise I can handle before my leg and ankle are swollen like a balloon and I am in tears.  It so hard to be the fat mom at my daughter's school, the one who cant do field trips b/c of the walking.  Its heartbreaking for me!

So, I went back to my PCP and did the 6 months worth of insane dieting and exercise and lost NOTHING!  I went back and forth between 310 and 299.  I ended at 304. I am 5'5, maybe 5'6. Its humiliating! I try and try and nada, nothing, zip, ziltch.  My paperwork was resubmitted about 2 weeks ago and they said between 2 and 6 weeks for an answer, but as hard as I try I cant stay positive I am so sure they will find some reason to say no.

Its strange, I sit there for what seems like ages and look at all those before and after pictures and I cry!  I cry!!  why is that?  Because all I want is to include my own!!!

I really just need a friend right now.

Hi Vicki, We all understand your frustration!!!  You just can't give up!!!  There are a lot of people who have went through what you are going through, and have had the surgery.  First I would get in touch with your Imsurance company, and find out exactly what you need to make an appeal.  Also let them know what you have done already, and what it is you need to do.  I hope you find the answers you are looking for.  If you need any help, please let me know.  I will be praying for you.  Good-Luck!!!

I have NJ BC/BS PPO-  NJ Plus.  I started with a BMI of 74....  don't get discouraged.... You're looking for support in the right place!       It took me over 2 years to get approval for the type of surgery I wanted,  but it happened!   And now, 15 months later...i am so much better.          Where in NJ are you,  North,  South?    Keep posting!   Mary C

I am from Southern Central Area.   Point Pleasant.........

I also had Nj Plus. they approved my surgery in 1 hour after getting all of the paperwork. I had a BMI of 43 and some co-morbidities ( diabetes, hypertension, high cholesterol) Just keep  accumulating your paperwork. I know it's frustrating but it is worth it!

OK,  I'm officially jealous......  1 hour approval....  aarrgghh...  in 2004, I had to go thru 2 levels of appeals, where I had to present my health history, and beg....   and then, just before the civil court date, they changed the WLS policy.....   aarrgghhh....   I'm glad for you, but mad for me!!! I still think BC/BS is the Evil Empire!           Mary C

BCBS certainly has their moments, but so far I have been lucky. My approval was 3/07 so maybe they were lossening up at that point.  I have heard other problems with them. My doctor supplied a template letter for my primary so the primary would know what info was required. No guessing. maybe that and the comorbidities helped. One thing I have learned from othe rposters- my fills with NJplus are just $10 co=pays for offic visits. That's a big plus.