BCBS of IL...denied for gaining 10 lbs from edema???

You know every day I call them it gets more interesting. I get my EOB's on line..and last night was looking at an EOB and saw there was a place to send msgs to BCBS of IL..so I fired off a letter that said this: ************************** Please advise me status of my pre-approval for gastric RNY surgery. The additional info from my surgeon's office has been faxed on 10/09/06. I have met my duties by paying my premiums and meeting ALL your criteria you requested for this surgery, as well as using a PPO provider that is on your list that you work with....EVEN though it is a 2 hour drive for me. I have met my end and expect that you do the same by abiding by your contractual duties and approving this surgery that is medically necessary. I am in the insurance field and am familar w/contractual duties and the responsibility that you have to uphold them. AS per my paperwork submitted you will see I have met the 5 years history, MORE than 6 months of supervised diet w/my PCP & weigh****chers, my psych eval, the nutrition class, I am well over 18 and my BMI is at 50 and has been over 40 w/co morbidities for over the last 5 years. Thru weigh****chers I also received counseling for excercise..that being a member of weigh****chers and going to the meetings emcompasses all of your criteria on what the weight loss program component should consist of: every meeting at weigh****chers is about a different subject.. counseling on exercise...lifestyle changes, .....eating habits... behavior modifcation and why we eat when we do. This meets your criteria of: A program will be considered appropriate if it includes the following components: 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. Behavior modification or behavioral health interventions. Counseling and instruction on exercise and increased physical activity. Pharmacologic therapy (as appropriate). Ongoing support for lifestyle changes to make and maintain appropriate choices that will reduce health risk factors and improve overall health. ** I have met everything us ask and I expect you to adhere to your contract. AND just so you know.. I am NOT going to just go away. I have rights and will enforce them accordingly. *********************************************** the response I got was this: ************************************** Dear Ms. Mixon: Thank you for the opportunity to assist you with your recent inquiry regarding eligibility of benefits for gastric bypass surgery. We carefully considered your request but found that gastric bypass surgery would not be eligible under your health care plan because the patient gained weight on the supervised weight plan. Unfortunately, our reply could not be more favorable. The documentation submitted has been forwarded to our appeal department and you will be notified of the outcome in 30-45 days. If you have any further questions or concerns, please contact the Customer Service Department at 1-888-652-4013 between the hours of 7 a.m. and 7 p.m. Central Standard Time or via Blue Access at http://www.bcbsil.com/statefarm/. Sincerely, Jennifer B. Blue Cross Blue Shield of Illinois Customer Service Center ***************************************************************************** I replied with this...(the are forwarding it to the appeal dept****************** ******************************************************** Thank you for your response. I will await the appeal process. In your policy it says nothing about successful weight loss has to be the result before approval- it simply says that "It is expected that appropriate non-surgical treatment should have been attempted ".....which it was. The weight gain was not as a result of my diet - but if you read my notes..it is from severe edema which I was put on Lasix & a potassium pill to control the EDEMA. Your policy reads as follows: "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.] ". I would like this info and this letter to be forwarded with my appeal. And a response received. *********************************************************** Have you ever heard of this??? Can they deny it because I have gained 10 lbs from edema?? I called my benefits dept today in our corporate office and complained. She told me that once I get the first denial...then it goes to BCBS appeals dept...if THEY deny it .then I can send it to our benefits TOTAL REWARDs appeal dept for the final decision...and the final decision is theirs ..as they are the ones who writes the policy.... Any Advice? Thanks. Tracy

Sorry, I do not have an answer for you other than getting your physicians involved and to do a peer to peer review. It sounds like a non physician read over your file and noticed the 10# issue and rendered the decision. Time to get fighting made and stand up for your rights. This does not seem fair in the least. Chris

Been there done that! I got TWO denial letters about a week apart. First one was that I had GAINED weight during my supervised diet. My pcp fired off an appeal listing all my weights - showing that I HAD lost weight. Next denial letter was that since I lost weight on my own, obviously I did not need the surgery They will give you EVERY denial in the book - keep on em and do not give up! I got tired of fighting with them and let them win. I ended up switching jobs with better insurance and got approved in a couple weeks. Hang in there!

Thanks for the info. I am just going to keep fighting. LIke my dr. said...if I could lose weightl...why would I need the surgery. Further more their policy does not say anything about having to have a "successful" weight loss to be approved.... ??

Hi Tracy - That really stinks. Stick to your guns and don't give up. They are just trying to push your buttons so you will give up. Don't. Hang in there. Christina

Hey Tracy ... I really think you need to get your surgeon involved. I was originally denied because my company had an exclusion, however, upon appeal by my surgeon (not me, not my PCP) that this was a medical necessity, the decision was turned around. Good luck ... hopefully the automatic appeal will work and you won't need to go further. Hang in there. Karyn

this is just a question, but why did you have 10 pounds of edema? that is pretty severe. What is causing it? your Doctor needs to look at that and make sure all is well before you do have surgery. altho I dont really think it is bcbs's job to determine if you are medically stable enough to have surgery, you need to be sure that you are by working with your doctor. (My sis had a heart attack , and if she goes up 5 pounds with edema she has to call the cardiologist so he can check her for congestive heart failure) in the meantime - do the appeals and good luck!!!

I am not sure. I have had edema pretty bad lately. My white blood count has also been high and my liver function test. BUT I have had a whole realm of tests and they cannot find anything. Not sure what is making the white blood count high - but the oncologist signed off for me to have the surgery. & my doctor changed my medicine from Triamterene/HCTZ 75/50 to a strong Lasix and potassium. I was assuming maybe all the weight is making the circulation in my legs bad. She did some kind of circulatory test for my legs..but it came out fine. My CRP count and sed rate count is high as well. The oncologist just said whatever it is just eventually go away or show. She said the tests just indicate some kind of inflammation marker. I have had an echocardio gram done...that came out fine too. So she said I was fine to have the surgery... WE will see. thanks for asking. Tracy M

We had the same the problem with Personal Care PPO of Illinois. Every time I appealed I sent a letter to the department of Professional Regulation with the state. My last letter I had to send a copy to our attorney and to our state senator in hopes that they would help. Well low and behold we got a approval last week and have surgery schedule for Dec. 6th. I hope that this helps you. We have been trying since Feb. I think sometimes they want to see how many hoops you will jump through. Good Luck!!!

Oh my dear, I DO know how you feel. I went to my first seminar in January of '06. As you may know at that time BCBS of IL required 12 months of DR supervised. So I did my little duty for 13 months. In March of this year, we submitted ALL our paperwork, INCLUDING pre-surgical testing. I was denied, because they stated my Dr. did not have adequite notes at all my visits describing what was discussed. My Dr. supplied a letter saying we discussed the meal plan I was on, and also an excersise plan to follow. So after that, they said that I MISSED a month. Now it was something like....I went June 1st, and then again on June 30th (thinking that was 30 days apart) and then again on August first. They said I did not have a JULY visit, so they were not "consective", so I would have been going faithfully since them, and meanwhile hired an attorney, and shelled out a nice amount of cash to help this go through the appeals process quicker. Then as you know...Wham, they changed the rules, so now they will have NO REASON to deny me right? WRONG answer. I had the same thing happen, in that I gained during the last 4 months of Dr. supervised, #1 because I was disgusted and depressed with the whole situation, but #2, because my joint pain and arthritus are now so bad that I am getting close to being immobile. The only type of excersising I can do right now are arm excersises. Walking up my own stairs is painful. I then got a decline letter stating that I was not being "compliant" on my Dr supervised diet, blah blah blah. I think that BCBS of IL could possibly be the worst insurance in the world! I'm at my wits end, I seriously am. I had planned on having my surgery at Kishwaukee Hospital in Dekalb. Where are you? Here is hoping and praying the best for both of us. Pe@ce, Nancy