Question:
Anyone with BC/BS of Illinois had surgery since they changed their guidelines?
I was denied surgery back in October of last year. I am appealing thru Walter Lindstrom with a 25 pages appeal letter that he sent on January 5th. I am still waiting. I thought they only had 30 days to respond and it has been 60. I asked my lawyer if I should contact them and he said no that he had asked them to only talk to him. People that I work with who have the same insurance as me are getting their surgeries approved. At least one of these persons has no co-morbid conditions and a BMI of 40. I on the other hand have a BMI of 47 and I have 5 co-morbid conditions. My question is this: is there anyone else out there with BC/BS of Illinois who have had their surgeries approved and would you be willing to share your info with me so I can determine if I am being discrimated against? Thanks for all your replies. — Janice B. (posted on March 6, 2004)
March 6, 2004
Let me start off by saying, I have not had the surgery...yet. Like, you I
am still in the process of meeting BCBS's guidelines. What I do want to
tell you is that it seems BCBS will not approve unless you have done the 6
month supervised diet no matter how many times you appeal, no matter how
many co-morbids you have, and no matter how high your bmi. I have heard
several stories from others who say they are in the midst of appealing with
Mr.Lindstrom as well, but each appeal has been denied and there reason is
still, "no 6 month supervised diet". This means that you have to
have substantial documentation each and every 30 days showing you have
weighed in, that you kept a diet and excericse journal that your doctor
reviewed, documentation of any changes or modifications your doc wants you
to make, documentation from a nutritionist that you have gone through
nutritional therapy/counseling, documentation that you have been monitored
while increasing your activity, etc. It is my firm opinion that BCBS is
just trying to buy time hoping that you will give up and go away or that by
the time we all finish this silly documented diet BCBS will have changed
their guidelines again or they will have stopped covering WLS alltogether
because you know BCBS of FL has already notified the suregeoms in Florida
that they will no longer cover Gastric Bybass surgery effective Jan 2005 so
it is just a matter of time before other BCBS entities follow. I expect
that BCBS of IL may do the same or my employer may exclude it in our policy
in January 2005. My advice is to not waste any more time. Do the supervised
diet, get a nutritionist and have them review your logs and keep notes of
your weigh in's. Go to support meetings and have that documented also, that
you were a participant. Go to your doctor once a month and complain about
all your ache's and pains and any problems related to your obesity. After
all is said and done (and documented!) you will have more to stand on. For
the record, I do not agree with having to jump through the hoops, but if it
means I can have the surgery by the end of the year then I am all for it.
— ToriJ
March 6, 2004
all bcbs of IL policies are not created equal. your specific policy is
determined by what your employer negotiates/ pays for/can afford to pay
for. I personally was approved with in days of asking without any hassle
at all.
— **willow**
March 6, 2004
As was mentioned before, it does depend a lot on your employer, but if
other people at work are getting approved, that might not be it. Your
appeal letter should have stated EXACTLY why you were denied. If it was
because of a lack of supervised diet history, no appeal will help until you
meet that criteria. I had BCBS of IL through the Chicago Public Schools
when I had my Lap RNY done in Dec. 2000, and they approved me within a
month with no hassle at all. Good luck! Maria (PS, I had a BMI of over 50
with plenty of co-morbs)
— Maria H.
March 6, 2004
You are not alone, I was first denied in October of last year too, and I
also hired Walter Lindstrom. They denied me because I had very little
documentation of a 6 month or more MD supervised diet. Even with a lawyer
I don't think they are going to budge. Before I started my pre-op work up
in April of last year I called Blue Cross and asked them if they covered
the surgery and what criteria they required. I remember exactly what the
girl said on the phone and I should have asked for it documented on paper-
she said I just needed a BMI of 40 or more and co-morbidities. They must
have changed their criteria right after that because now they are saying
you have to have that 6month diet before they will make a decision. From
talking to other people it seems sometime last summer is when they became
strict with the criteria. Because before that I know a lot of people who
were approved within weeks of the first letter. If you were denied because
you didnt' have any doctor supervised diet I suggest you start one now. I
am waiting for their response from my 3rd and final appeal.
— Kara J.
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