BC/BS of Ill?

Does anyone have BC/BS (PPO) of Ill? and if so did it take long to get approved for gastric bypass ?

I have BCBS PPO. Call them and get the criteria. I thought that I had everything upon first submission, but at that time, they wanted a 1 year supervised diet. We tried to explain to them that I had been dieting for years and years, but that is NOT what they want. You must go to the doctor once a month, every month to be weighed and checked. My doctor put me back on diet pills for this. Every month, I took in a form stating my goals for the month, which ones I'd met, and new ones for the next month and also included a sample menu for a day. After 9 months, BCBS changed their criteria to 6 months, I sent them my diet history and was approved within a week. If you have each and every little thing that they require, approval is swift. Good luck in your journey! Dawn

yes i have it. you should get the criteria from bc bs it is on there website or you can call customer service and they will send it to you. i did 6 month supervised diet and met with my doctor every month. I get approved in 2 weeks!! at first they tried to say i did not have everything but my surgeon went to bat for me and it was approved!! good luck

I've looked on the website and didnt see anything or where to find anything on it. why did they have you do a 6 month supervised diet? co-morbities or BMI are not enough?

nope BMI and co-morbities are not enough!! if you type in gastric bypass on there website then the policy should come up. you also have to have a psych eval!!

I have found that you cannot find it on the BCBS website. I called the ins. company and had them send my the "qualifications" for gastric bypass. They have changed to the 6 month diet. It goes by really really quick. I have my last appt next week and I am done!! I have heard that they always deny the first time but as long as you have your paperwork you will be fine when you appeal. But you do need to see your doctor every month. Hope this helps! Kelly

Kelly, I have bcbsIL. They are difficult to deal with. I completed the 12 month diet to nly find out they changed it back to 6 months. I was denied before I did the diet. I tried again after completing the diet and had an attorney submit for me and I was still denied. They claimed that I didn't have the documentaion of the 6 month diet. My lawyer submitted my appeal and I think I am close to getting approved. I have heard many people say that they have had a hard time with them. Just keep on them and don't give up. Below you will find the medical policy on Bariatric surgery You can also check it out at www.bcbsil.com then click on Medical Providers then click on medical policies. click on all policies. it is on page 15 Here is the info Coverage: 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: Body Mass Index (BMI) of greater than or equal to 40 kg/meter squared; OR 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: 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. 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: The absence of significant psychopathology that would hinder the ability of an individual to understand the procedure and comply with medical/surgical recommendations. Any psychological co-morbidities that are contributing to weight mismanagement or a diagnosed eating disorder. Patient's willingness to comply with preoperative and postoperative treatment plans. Significant relative contraindications for surgical treatment of obesity include: Mental handicaps that render a patient unable to understand the rules of eating and exercise and therefore make them unable to participate effectively in the post-operative treatment program. [An example is a patient with malignant hyperphagia (Prader-Willi syndrome), which combines mental retardation with an uncontrollable desire for food.] Portal hypertension, which is an excessive hazard when laparoscopic gastric surgery is performed. Age greater than 65 because for these patients the weight loss is less effective, the duration of benefits is shorter and the risks of the procedures are greater. Good luck. If you have any questions just PM me. Mike

I have had a hard time with bcbsil also. They have denied me also for the diet. But I do have the documentation. I've been trying since last July. I have been calling them all the time but they are not helpfull at all. Maria