Question:
Why does BCBS of IL have 6 month and 12 month requirements?

My doctor submitted a letter of medical necessity to BCBS of IL for Gastric Bypass surgery and included a long 5 page letter detailing co-morbids and why I felt I needed the surgery. Anyway, I haven't been denied, but I received a letter saying to complete their review they need visit notes from md supervised weight reduction program from the last 12 months and nutritional counseling. I do not have these because my previous pcp never brought up a specific regimen with me. I know my weight is documented at least 3-4 a month for several years because I have severe problems with asthma and I was in the pcp's office several times a month. She would only ask me once every few months was I excercising and we would talk breifly about my eating habits, but nothing more than that. Anyway, why do you think they need 12 months from me while I read other posts that say BCBS just asked them for 6 months of supervised diet? I called and asked them for their explanation of benefits or their requirements and writing and they assisted they don't have anything to give me and she stated that the medical review board makes the decision for approval or denial. Should I hire a lwayer now or wait and possibly waste time and why do I have 12 months opposed to 6 in your opinion?    — ToriJ (posted on February 5, 2004)

February 5, 2004
They want the same from me, 6 to 12 month MD supervised diet. Send them any and all documentation from your doctors about diets and wieght issues. Have your doctor type up a report that explains you have been on many diets in the past and have failed. In the mean time, I suggest you start your MD supervised diet and have your doc documented everything! Trust me, I don't think they will budge, Blue Cross wants that diet before they will consider approving. I also asked them awhile back for their requirements for the surgery in writing and they could never produce anything for me. It doesn't make any sense to me. I hired a lawyer after my first denial and I don't think it makes a difference, they still say they want the diet.
   — Kara J.

February 5, 2004
I don't have BC/BS, but I had the same problem with Aetna. Instead of fighting them after the second denial, I had a Dr. supervised diet for 6 months. (their requirement at the time). We kept very concise notes and after 6 months I resubmitted. They denied again saying I didn't have a nutritionist. I explained to them that the denial letter only said a 6 month supervised diet. I faxed them the denial letter and they changed their decision. However, I think I'm one of the lucky few. Insurance companies are really making folks jump through hoops to have this surgery. My feeling is, if there hadn't been so much publicity, i.e., Carnie, Al, etc. then maybe things would be easier for us regular folks. JMHO.
   — Julie S.

February 5, 2004
I have Aetna, and guess what? After jumping through there ridiculous hoops and finally getting everything they asked for( 6 months doctor supervised diet, 5 years of doctor documented weight with BMI over40) I submitted for approval and they denied me saying that they now needed a 6 month doctor supervised weight loss regimen WITH A DIETICIAN OR NUTRITIONIST! I of course through a shit fit. And after I calmed down, I hired Walter Linstrom. www.obesitylaw.com He was well worth every penny(which wasnt all that much) and I paid extra to have him type my appeal letter in 3 days. I received an approval after 2 weeks. Save yourself a lot of headaches, frustration and time. Call Walter Linstrom. and tell um Jeanne sent you
   — Jeanne S.

February 5, 2004
I found out Wednesday that Aetna wanted me to be on a month supervised diet with a dietician. The lady also told me that I would have to check in with my doctor regularly and I would have to be doing exercise on my own. In six months they only need me to lose at 5% of my body weight. That isn't very much in six months. I think the whole 6-12 month thing is stupid. I have been "obese" for the past 17 years and have pictures to prove it. I don't know what a stupid dietician is going to do.
   — manbandone

February 5, 2004
I had a similar problem with Aetna, was denied the first time, and like the other posts you have received, I had to do 12 months of doctor visits. I got copies of every visit I made and highlighted every note my doc had made related to my weight, even if it was not specific to weight loss. I even highlited my weight and B.P. for each visit. For the last 6 months before I appealed their decision to deny, I mad sure I saw my doc every month and had them code the visit for obesity. I was told by a service rep at Atena the nutritionist requirement could be met by going to Weight Watchers. You might check that out. I then sent them a copies of my W.W. book so they could see I had attended. I also had to get documentation of my weight for 5 years previous. Lots of hoops. If I had been denied the second time, I was planning to hire Walter Lindstrom. I hear he is the best. Keep the faith. Even if it is ridiculous, my advice(free) is to follow exactly what they say. As an individual, we have little power against the big guys, and I know it's hard to stay positive. Just be sure you write everything down: phone calls, dates, person spoken to. That's what saved re: the nutrition thing. Pat Finnegan
   — Patricia F.

February 5, 2004
TORI DO NOT WASTE YOUR TIME WITH A LAWYER. THE ONLY THING YOU CAN DO IS TO BLAME ALL THE PEOPLE WHO HAD THE SURGERY THAT REALLY DIDN'T NEED THE SURGERY AND WAS TRYING TO FIND A QUICK WEIGHT LOSS SOULUTION. dO THE 12 MONTHS SUPERVISE DIET WITH A M.D. i WAS DENIED IN DEC. IN THE BEGINING OF DEC/2003 THEY HAD CHANGE THE QUALIFICATIONS FOR THE SURGERY. I HAVE BEEN ON A SUPERVISE DIET FOR A MONTH AND ONLY LOST 6 LBS BECAUSE OF MY DISEASE. I'M GOING TO TRY @ 6 MONTHS TO SEE IF THEY WILL GO AHEAD AND LET ME DO THE SURGERY AFTER THEY SEE HOW UNSUCESSFUL I AM WITH A M.D
   — MARLO M.

February 6, 2004
OK, I think you might have a case if they can't provide you with this requirement in writing. Talk to Walter Lindstrom, I think you can e-mail him with questions and he will let you know whether he can help or not. Then you can decide if you want to hire him.
   — Ali M