The Peer Review didn't go well...............

 Ok. 

Now, was this letter from the PCP, an IPA or PMG or BCBS?

Also, have you called DMHC and asked if your BCBS insurer is governed by DMHC?  I am guessing that they probably are, but I am no expert.

Did you see your PCP over the course of your 6 month weigh****cher's adventure?

Do you have a copy of the specific "medical policy guidelines" used in making the decision?  There is probably a paragraph in tiny print that telly you that you hae aright to receive a copy of the guideline used in making the denial.  Follow the directions on how to obtain a copy.  Be prepared to be stonewalled.  They may try to say you can t have it.  Just keep quoting the blurb in the letter from them saying you have a right to get a copy.

You said "6 months of weigh****chers which they said was accepted".  Who said it was accepted, when and how?  If you have it in writing  or could get it in writing that would be awesome.  If not, know that the person who told you that is either misinformed, confused or a liar, in this case. 

Honestly, just getting your hands on this letter has you a tiny step closer.  I know it doesnt feel that way...

The letter was from BCBSIL to my WL surgeon, It was after that letter that the Surgeon requested the Peer to Peer Review and she said that they would not Budge.
Although I was seeing my doctors for other medical reasons while I was on Weigh****cher's and they knew I was enrolled and participating, we really did not discuss it.
This is the way the medical policy reads:

The following criteria and guidelines have been developed to judge eligibility for coverage of bariatric surgery for the treatment of morbid obesity.

To be considered eligible for benefit coverage of bariatric surgery for treatment of morbid obesity, the following three criteria must be met:

• A diagnosis of Morbid Obesity, defined as:
  1. Body Mass Index (BMI) of greater than or equal to 40 kg/meter squared; OR
  2. BMI greater than or equal to 35kg/meters squared with at least two (2) of the following co-morbid conditions which have not responded to maximum medical management and which are generally expected to be reversed or improved by bariatric treatment:
     • Hypertension,
     • Dyslipidemia,
     • Diabetes Mellitus,
     • Coronary heart disease, and/or
     • Sleep apnea.

[Note: A BMI formula can be found in the description section of this policy.]

AND

• At least a five-year history of Morbid Obesity supported by medical record documentation.

AND

• It is expected that appropriate non-surgical treatment should have been attempted prior to surgical treatment of obesity

Non-surgical treatment of morbid obesity appropriateness criteria:

• Medical record documentation of active participation in a clinically-supervised, non-surgical program of weight reduction for at least 6 months, occurring within the twenty-four (24) months prior to the proposed surgery and preferably unaffiliated with the bariatric surgery program.  [NOTE: The initial BMI at the beginning of a weight reduction program will be the “qualifying” BMI used to meet the BMI criteria for the definition of morbid obesity used in this policy.]
• A program will be considered appropriate if it includes the following components:
  1. Nutritional therapy, which may include medical nutrition therapy such as a very low calorie diet such as MediFast or OptiFast OR a recognized commercial diet-based weight loss program such as Weigh****chers, Jenny Craig, etc.
  2. Behavior modification or behavioral health interventions.
  3. Counseling and instruction on exercise and increased physical activity.
  4. Pharmacologic therapy (as appropriate).
  5. Ongoing support for lifestyle changes to make and maintain appropriate choices that will reduce health risk factors and improve overall health.

Surgical Program for the treatment of morbid obesity documentation requirements:

• Documentation that growth is completed.  [Generally, growth is considered completed by 18 years of age or with documentation of completed bone growth.]
• Evaluation by a licensed professional counselor, psychologist or psychiatrist, should be completed within the 12 months preceding the request for surgery.  This evaluation should document:
  1. The absence of significant psychopathology that would hinder the ability of an individual to understand the procedure and comply with medical/surgical recommendations.
  2. Any psychological co-morbidities that are contributing to weight mismanagement or a diagnosed eating disorder.
  3. Patient’s willingness to comply with preoperative and postoperative treatment plans.
• Today I called and asked if they cover a Medical Supervised Weight Loss program and I was told that that is excluded in my policy..........Go figure.....

I just call DMHC and they would have no jurisdiction over Blue Cross Blue Shield of illinois.
I have to call Dept. of Insurance of Illinois...  UGH!!!

Hi Jeni,

Big hugs and positive thoughts for the attorney taking on your case.  I'm sure they will get you the results you have been waiting for.  Keep high spirits burning, we're all rooting for you!

Hugs,
---jan---

Thanks Jan.............I appreciate it!
How have you been?  I hope good!  So are ya skinny yet?  I know you have been doing wonderful and working hard!
Take care, Jen

Hi Jen,

I'm doing great!  Been away a lot with my folks visiting and will be for another week or so.  But I sneak in and read a few!

I'm definitely working towards skinny. lol

Holler if you need anything!

Big Hugs!
---jan---

High/Consult/RNY/Current/Goal
330/   289 /261.9/242.6/150

Jeni - PLEASE appeal to the DMHC for an IMR, I did and won!  I am having the DS which Kaiser does not do, I requested to be refered out and they denied me twice.
I appealed to the DMHC for an IMR which they granted.  The IMR ruled in my favor!
My first letter went to Kaiser March 17,2008 I was approved July 16, 2008.  Kaiser is paying for the surgery!!!

You can also go on the DMHC web site and read previous decisions, this is very uplifting because most are for the patient!

Let me know if I can be of any help.

Thanks Penny........
I am not sure how to do all of that, or which way to go.  Should I wait and see what happens with the appeal through Lap Band and Obesity Law First?  I am starting to live and breathe this and I don't know if I should just take a step back to keep my sanity or what.
It is starting to get to me.........lol  (starting...well that's a joke!) 
All I want is a better way of life!!!  To be healthy, not hurt, and be more active with my husband and dog and grandbabies!  Ugh!!!
Sorry for venting!!!  Well need to go finish getting ready for work.
Thanks again Penny!!!
Jeni

Thanks Neeley I appreciate all your help.
The denial letter was from my Insurance Company to my Bariatric Surgeon.
Their whole issue now is the 6 month Medically Supervised Weight Loss Program which of course my plan does not cover.  They said I should have went to my PCP the whole time I was going to Weigh****cher's and had her document everything and include an exercise program.
I'm just so confused!!!
Jen