Question:
DENIED by Stupid BC/BS of Texas! Please help!

I was denied today from BC/BS of Texas due to not being MO for 5 years and not having the 6 month supervised diet. I am fine and can handle the 6 month thing, but what the heck do you do about the stupid 5 year MO rule? What are ways around it? I have many co-morbidies and sent in 25 pages of documents stating so....now what? Please help : )    — 1fatgurl (posted on October 16, 2006)

October 16, 2006
Sorry about your issues. You can do a couple of things. You can appeal you case to the state insurance dept and or get a Gastric attorney and see if he can help you. B/C-B/S is very tough lately. The 5 year thing is one I have not heard of before. The 6 months is what most all insurance companies demand. Good luck
   — Steve Cohen

October 16, 2006
I have BCBS of Texas HMO through the government and they approved me with no problem. The only thing I would tell you to do is to appeal the decision and while waiting on that go ahead and start doing your 6 months of supervised diet. Do you have bariatric coverage? You may want to check into that first.
   — The One

October 16, 2006
Hang in there! I have BCBS of IL & was denied because I didn't have 12 mo. Dr. supervised diet. (had the 5 yr MO). I learned a couple of things that might help there. Every mo. when I went to my Dr. appt. the 1st thing I was there for was weight management. She had to write that 1st in her notes & she had to code that 1st on the bill. I got a copy of that section of our insurance policy & studied it so I would understand exactly what they wanted (Had not done that the before, I relied on what they told me by phone.) I did 12 mo of Jenny Craig, but they may have liked it better if I had done 12 mo. of Opti-Fast, as that was listed in the "possibles". So, my 12 mo. is over & my request for review of my denial went to them yesterday. I'll let you know the outcome. I considered a lawyer (there are OH ones out there), but I decided I would give them a 2nd chance & pray they will give me one too! God Bless! Email me if you like. [email protected]
   — asinmouse

October 16, 2006
I always recommend filing an immediate appeal and plan to move through ALL appeal levels to the mediation/legal level where these "medical protocols" are more difficult for the payor to defend. A structured approach is critical. It's important to FIRST identify ALL issues and requirements which any payor can use to delay/deny authrorization/payment. Sending tons of info may not address the issues - and unless you specifically say "...this is an " x" level appeal to the decision of..." then you're only doing dialogue and not moving towards a binding decision. Regarding the 5 year MO rule - this may not be a valid basis for BC/BS denial unless the requirement appears in your benefits statement - or can be shown to be in their published medical protocol - and the best way to force BC/BS to prove that is with a formal appeal process. Best Wishes - keep pushing - this is an evolving area of coverage for most payors. Lan, [email protected]
   — LanAtPtsMedicalClaimsAssist

October 16, 2006
I have BC/BS of Texas and got approved. Do you actually have 5 years of MO? If you do, you should be able to document that through some doctors records - maybe your annual gyn appointment? Other than that, I'd go with what the others are suggesting.
   — KC

October 17, 2006
I'm thinking right off the top a letter from your doctor telling them other medical issues which are a direct result of being overweight would be in order as well. Things like sleeping disorders, asthma, joint pain, incontinence, etc., and add that letter to the appeal process mentioned by another user. Perhaps it will help and perhaps it won't but it is harder for them to argue never the less.
   — Merredeth

October 18, 2006
You will not really be able to get around the 5 year rule. My sister tried with a different insurance company and they would not budge. Chris
   — ChristineB