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
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