What BCBS of IL really means...

I made the call today to BCBS of IL to ask them what they are asking for in the 12 mo supervised diet. Many of you with this insurance have read the policy and know what I am talking about. The policy reads... "A documented failure of twelve (12) continuous months of compliance with medically supervised non-surgical methods of weight reduction. Medical supervision must occur under an MD, DO, or nurse practitioner within the previous 24 month period prior to the request. . A medically supervised weight management program is expected to consist of: Nutritional therapy or medical nutrition therapy including a very low calorie diet (e.g., MediFast or OptiFast) unless contraindicated., Behavior modification or behavioral health interventions, Supervised increase in activity, Pharmacologic therapy (unless contraindicated), Maintenance support to continue to encourage nutrition choices to reduce health risk factors and maintain a healthy lifestyle. "[taken from bcbsil.com/medpolicy] Today after talking to Alisha, she advised that the medical records that I submitted from my doctor were not good enough.... what they need are: - each visit separated on a separate sheet -the beginning and ending date -any diets and exercise within that period -any lifestyle changes within that period -and progress notes Apparently the information that my doctor had put in my medical records that were on separate sheets was not detailed enough for them. Not only that, they should list this information in the medical policy to give their members a better idea of what they do expect instead of wasting their time. Nonetheless, I felt that this information might help out just one person so I thought I would share it. Good luck! Beth M

I know what you mean, I too have BCBS of IL, and have been trying for over a year. . I just got the same letter on Thurs. June 30. They had more things on this one then they did on the one last year. Hope you luck. Lisa

YOu have got to be kidding me!! I also have BCBS and they want EACH VISIT seperated??? THat is going to be a huge packet of information - each visit they took vitals, blood, urine and I met with a nutritionalist AND physical therapist. Each time for the entire year?? They can not possible want all that information - I am not even sure my doctor will be able to pull all that information. Certainaly helps me out - I can for sure be expecting that denial letter as well. What a crock - my doctor detailed that and listed dates/weights/BMI and Blood pressure for each visit but not diets/excersise and lifestyle changes. WOW - not sure if this surgery is going to happen for me!!

Yes, I am in the same boat. However, my surgeon, Dr. Cahill at Little Company of Mary In Evergreen Park, IL has met with representatives from BC/BS to come up with a program that will satisfy the needs of the insurance requirements. I am currently at month 8 of 12 in their program. All of the patients of Dr. Cahill's that were enrolled in this program and have completed their twelve months have been approved. It took me a little while to get the courage up after my first denial to start this program, but it's not some thing i regret. I can hardly blame BC/BS for wanting to ensure that their patients can use the tool effectively and not die from complications or re-gain. I see a nutrionist and dietician/pcp every month, every three months I meet w/ a personal trainer and i met with a psych at the beginning of the program and will again at the end. I started on my 24th birthday- i said i've had enough with barely living and made a pact with myself to have lost this weight or on the road to WLS by my 25th birthday, and here I am. I've lost 23 lbs to date on my own- NOT GAINED ONE POUND in 8 months, which is some thnig I've not been able to say in 4 yEARS!!!!!!!! I am extremely pleased with becoming more knowledgeable about nutrition and health, and about the lifestyle changes I've made. Keep on trucking and you'll get there- remember how long you've been battling this on your own, and then think what's one more year? It's nothing but learning good habits and changing your life for the best!!!

Hi-I was finally approved by BCBS PPO IL on Tuesday. My surgery is scheduled for July 25. I began this process in April 2004. I was 5 months into the 6 month diet when they raised it to 12. I complied and finished all the requirements in March. Stuff was sent in early April and I was denied in May. I sent additional information on June 7 and got approval on July 5. I sent in excess of 155 pages of information. Luckily I was in the Bariatric Program at Riverside in Kankakee and had the coordinator doing much of the work. We originally sent in 1 year's Dr. notes, as well as all the letters and results from the tests and Dr's along the way. I worte a letter "an essay" really that included my story divided into three sections-the impact obesity has had on my family & personal life, my career, and my health. I got my medical records back to 1987 and highlighted every time obesity was mentioned, and each time a physician documented that a test result couldn't be relied on due to patient's "Body habitus" I went through my bookcase and wrote down all the diets I have tried and failed. I had to guestimate the dates and exact results as my memory doesn't go back too far.I included a letter from Jenny Craig. I made a spreadsheet of my weights since way bac****pt a daily log for a year of any increases in activity (I am currently unable to do an exercise regiment). The coordinator compiled all this into a bound book with sections labeled. We were very thorough and still I got denied. I firmly believe that this company denies all first time applicants. My PCP rewrote the letter in greater detail. He included that he didn't want me to be in an official exercise progran just yet due to health staus and conditioning level. He stated he didn't want me on diet pills or Optifast. I wrote another letter reaffirming my determination to have the surgery. We resubmitted some of the original information. Weeks went by and no word. I was blessed to find a customer service rep that took an interest in me and personally contacted the "powers that be" to check on the progress of my case. On the same day she contacted them, I got the approval. I think my stuff was just sitting on a pile waiting for another denial. Call every day and keep the name of the person you talk to and what was discussed. I went through 7 reps before I got one who cared. Don't give up-Sherry

What you all have to realize is just because you all have BXBS does not mean that the requirements are the same for all of you. The majority of the information will be the same. However, depending on who you have your insurance through and what type of policy they sometimes require different things. For example a self funded insurer can require you to jump through many more hoops. This would be if company A pays BXBS to admin the benefits, but the payments are funded by company A not BXBS. I used to work for BXBS of IL and know all of the companies that we handled at our office did not carry the same criteria for meeting eligibility. Also with BXBS even if you policy says WLS is not covered - depending on the type of coverage - there is a chance that it can be covered if it is determined medically necessary. It doesn't happen very often, but it can and does happen. I wish you all the best of luck!!

BEEN THERE DONE THAT. This is what BCBS of IL is doing to everyone. I first tried to get approval with them in August of 2003 to November of 2005. I was denied 3 times I hired Walter Lindstrom and even he couldn't help. They don't want to pay for the surgery. (period) They will do everything in their power to deny you. I have since gotten a new insurance Blue Cross of Ca and I was approved in 2 days! Maybe you could look into getting a different insurance? To me I spent a year battling with them and I wasted a lot of time. Maybe you can try to get private insurance with Blue Cross of Ca? It might be expensive but at least you will get your surgery. Expensive but cheaper than paying for it yourself. I would say it would cost about $400 a month for private. Thats $4800 a year. But you could drop it after a year from your surgery.

I don't understand your situation as well the posters before you..maybe you could shed some light on this for me. DId you complete a comprehensive 12 month diet, including meeting with a nutrionist, dietician, personal trainer and psychiatrist and still BC/BS denied you? As it stands right now, my surgeon has developed a program tailored specifically to BC/BS and their 12 month requirement. Every patient that has been in this program and followed it like they were supposed to have been approved. I hated BC/BS for their 12 month rule- until i started it myself. I realized, and please share your opinions, that they were attempting to look out for the patient as well as their shareholders by not rubber stamping approvals on every request that has come in. I am suspecting they do this because of the high number of people that wanted it after it became "popular". I had thought they wanted to make sure that people who were barely overweight and had no co-morbids to speak of were not just trying to get the surgery. i had also thought the 12 month rule was to help the patient to become as knowledgeable about surgery as possible to ensure they were successful in the long term. I don't know, I want to believe this about BC/BS, but I am sure it's more so they can save money instead of helping people, because what corporation, that's in the business of insuring your health, truly wants to help any one? I don't know..but...I would say to meet with your PCP and try to find out what you can do to get approved. I am sorry I am not of more help.

Hi Meghan, Yes I went through the 12 month physician supervised diet, 12 months of nutritional visits, a comprehensive behavior modification program, a psychological exam, and $13,000 worth of medical tests. I also had a 12 month supervised increase in activity log. I also attended the monthly support group and did thorough research. I honestly feel the 12 month wait was beneficial to me. It was the denial afterwards that has my kniockers in a knot. The bariatric program at Riverside keeps updating their program to fit with the whims of BCBS. They have had nothing but trouble getting approval from them. Three of us in the program have this insurance and all three got the same blanket denial letter. I was denied in May-after a resubmit I was approved in July and will have my surgery in 18 days. I fully understand the concept of being careful not to give a blanket approval to everyone. I also think some insurance companies are letting people get the surgery when maybe they shouldn't. I also know people who are eating to maintain or achieve the minimum BMI. Don't ask me why. However, I have a BMI over 60, diabetes, heart arythmia, sleep apnea, pulmonary hypertension, hypertension, rheumatoid and osteoarthritis, etc. There should have been no question. I honestly believe that BCBS of IL denies everyone the first time around to stall, hoping you go away or your company will switch insurances. If you truly qualify be proactive and don't give up. Sherry

This entire series of posts just leaves me cold. My surgery date is July 25th and BC/BS isn't making anything easy right now. My surgeon's office has had to submit and re-submit information - even though it was confirmed received by BC/BS - they claimed they never got it. I just received a 'we can't make a ruling without additional information' letter that was anything but clear and when I called to ask for some clarification, they couldn't tell me exactly what they needed. So, I'll be submitting what I think they asked for (plus maybe something more, if I THINK it MIGHT be what they asked for) and crossing my fingers. It's getting way too close to the surgery date and I'm starting to worry about approval. And, before anyone asks - yes, I've been seeing my doctor monthly to discuss progress with diet and exercise and I've joined and attended the supervised fitness center at work. But I'm a lawyer and I know that if you want to make things hard on people there are a lot of ways to do it...