Question:
Why does it seem that BCBS of IL has different requirements regarding approval ?

I read profiles all the time. I am currently waiting on a response from BCBS of IL PPO regarding approval or denial. I have braced myself for a denial because I already know that from 01/03 thru 12/03 I did not have a supervised diet on file. I recently started a program 01/04 and I was content knowing that I should have the 6 months of supervised diet by 07/04. I read other profiles and from what I gathered I would need 6 months worth. Why is it that some AMOS members have requests from BCBS for 6 months of diet and some have 12 months? Isn't that suspicious? Sometimes they say supervised diet only, and/or nutritional counseling, behavior modification, increase in activity while being monitored and maintenance support. It can be just one of these requiremnts, two of those or all of them. So it seems like it is differen requirements for different people. What can we do as the insured, if anything? I had called BCBS in the past and asked them for written documentation of what they needed on 01/05/04 and I was told they didnt have anything in writing to send me regarding their requiremnts. I had never heard of such a thing. I assumed all insurance companies had a handbook with the explanation of benefits for your policy either on paper or online for us to review. Is their anything I can do as a policy holder to make sure I am not being treated unfairly when it comes to making a decision for WLS? I know I can hire a lawyer, but it doesnt seem as though BCBS is affected when a lawyer gets invloved.    — ToriJ (posted on March 19, 2004)

March 19, 2004
Hi There, One of my dearest friends works for BCBS. She told me back in September when I got approved for my LAP/rny that BCBS of IL was going to be slowing down approvals of WLS due to the many complications some were experiencing AND the biggest reason, people were turning to WLS before attempting to try all other routes. I have to agree on the second--I tried MANY things before even THINKING about WLS. WLS is drastic and should be a last resort. I tried EVERYTHING. It took me 18months to finally go from "Yes this is what I want" to do to actually having it. If someone has tried EVERY option short of sewing our mouths shut, then yes this is for you. My friend said that BCBS was CHANGING their criteria. I just called her and she said they are not completely denying WLS, but they are making it not as easy to get approved as it once use to be. Keep your chin up and I will be thinking of you!!
   — LisaL.

March 19, 2004
I had my surgery 9/25/2002, at that time I was aproved in days with only a criteria of being 100% overweight. I had given my doc a list of the many diets I had tried, the only dr. supervised was diet pills, 25 yeaars ago, and phen fen maybe 5 years ago for a month, just before it was taken off the market. BCBS did not ask ME for any documentation. They only recieved a letter from my dr. when I had called at that time, they verbally told me the criteria was 100% overweight, that at 5 feet, 260 # I would surely be approved. The people I spoke with were thrilled for me that I was having the surgery, told me several people in their office had had the surgery including a guy who was > 700 #. My consult was mid july, letters sent Aug 1, recived a week or so later and sent right away to the medical review board and approved. I had surgeryin Sept. because it woked for my schedule, I had to give 30 days notice at work or I could have been in surgery in August. I was too lucky for words... I also give a lot of credit to Bariatric Treatment center for their expertise in dealing w/ ins. companie. Too bad they no longer take BCBS.
   — **willow**

March 19, 2004
addendum : I do not think ANYONE should have to jump thru hoops to get this surgery. I think ht & wt should be it. I wasted years of my life doing all that crp that didn't work, and as we know it rarely ever works, so why do people have to be tortured for years on end trying EVERYTHING and being doomed to failure after failure. what a waste of time and life that could be lived.
   — **willow**

March 19, 2004
Because they don't have anything in writing leads me to believe that you can get by with at least 6 months worth of suprvised diet. My lawyer is requesting an appeal hearing with the appeals committee at BCBS of IL. You should request this too. After you've reached your 6 month mark I would try sending in your appeal with all of your food logs and MD diet notes. If that is denied ask for an appeal hearing. You will get approved eventually it's just going to take some time.
   — Kara J.

March 19, 2004
I was just denied by BC/BS of Illinois also. My company Catholic Health Initiatives (nonprofit hospital) administers this health plan and they sent my lawyer Walter Lindstrom a letter stating that I do not meet the guidelines for gastric bypass surgery when my bmi is 47. I also have diabetes, high cholesterol, arthritis, among other various illnesses. The whole reason is because I did not have any "evidence" of a medically supervised diet. My initial consult (with surgeon) was June 2003 and they repeatedly denied me due to a "lack of a medically supervised diet for five years". I sought help with Walter Lindstrom and he wrote a 25 page appeal letter on January 5th 04 and Catholic Health Initiatives sent me a denial letter yesterday March 18th 04. In their letter they indicated that they had sent him a copy of the criteria for the guidelines for gastric bypass ( which by the way they had just revised on August 15th 03). So I am in the process of asking him for that copy. It takes a while before he gets back to you (lawyer). But I made an appointment to a local doctor who specializes in the supervised weight loss arena even before I was sent this final denial. My first appointment is on April 8th. I knew in my heart that they would deny me. but I had to try anyway. Sorry this is so long, its just that I am so disappointed that and angry that someone has control over something that has helped so many people and I can't have it. If a person smoked for 20 years and all of a sudden gets lung cancer, so you think the insurance company would even dream of denying that person a potentially life saving surgery? I think not, and to ME there is NO DIFFERENCE! My advice to everyone is get on a medically supervised diet as soon as possible and document EVERYTHING. Hope this helps.
   — Janice B.

March 30, 2004
I also have bcbs of Ill. They denied me back in june 2003. saying I needed 6 months dr. supervised diet. I went to my pcp who gave me a low calorie diet to follow. when I went to him jan. 2004 he refused to write the diet up for me saying if I had followed the diet and exercised I wouldn't need this surgery. He also says fat people only need to push back from the table. I won't repeat my answer to that. just use your imagination. I am now searching for a wls friendly pcp. Good Luck to all trying to get approved.
   — Lisa C.

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