H.E.L.P (BCBS of Illinois PPO)

Can someone please assist me? I have BCBS of IL PPO and they are giving me the hardest time regarding the 12month Dr. monitored diets. Is there any way to get around/through this. My OB/GYN and PCP have sent over their medical records in which I know weight was discussed, but nothing seem to be working. I have completed ALL of the other requirements. To make matters worse, I'm working with a December 31st deadline. Any suggestions will be greatly appreciated.

Good luck I also have BCBS and have spoke with them IN detail about about they want for the 12 month. I am also working with a December 31st Deadline. I FINALLY got someone to tell me exactly what they need (now my file is still in review - went in on October 24th, so I am not sure that it is even good enough) but here is what I was told --Each visit must be on a separate sheet and list your current weight and vital signs (meaning blood pressure, pulse, etc). The doctor must also make notes about your diet and exercise within that period of time as WELL as any lifestyle changes within that time (like taking the stairs instead of elevator and switching to whole wheat bread or lowfat milk- stuff like that) --You MUST see the doctor (or a nurse practicioner) EVERY MONTH for 12 months in a row. You can not skip a month and you You can not just go in for weight checks, you must review your plan with someone each time and they must write PROGRESS NOTES on the chart. Also - the visit must ONLY be about your weight loss program and plan. NOTHING else can be on the notes! --They want you to see a nutritionist at EVERY visit - or at minimuim every three months on the plan --They also want you to see a physical therapist at minimium every three months on the plan. (I asked if the YMCA would be ok for this and she stated that if I had someone SIGNING off on my cards that I was there and Listed the beginning and ending date and times that would probably be OK) --Ideally they would also like you to be on some kind of liquid diet plan or weight loss drug. If your PCP decides that is NOT safe for you then he must STATE WHY he feels that is not a good option in the chart. It is a very strict plan and I HAVE heard of people being approved with much less detail, but not many (and I still have not figured out HOW they got approved) I would certainly start with what writing everything down that you have done as was suggested before and see what happens. Just make sure you send them in EVERYTHING you have, whether you think it might hel*****t. The more they have, the better. Good luck, I know how you feel - I am so stressed right now

Hi there ... I don't think I'll be of much help here, as I had my surgery over 2 years ago (and insurance requirements may have changed). I do have BCBS PPO of Illinois, and after my first denial, the surgeon sent a letter of appeal stating medical necessity and they apparently approved it! (BCBS actually said it wasn't "them" denying it, they said my "company" didn't want it covered ... but I guess the "medical necessity" must have worked.) Good luck to you ... please let me know if there's anything else I can do!! --Karyn

I have BCBS of IL but HMO. It took me 1 day to get approval. I have had them for a few years so they knew I took Meridia and Xenical (weight loss drugs), heck they paid for most of it. If your doctor can document previous weight loss tries you may be able to get through quicker. I had also tried Weigh****chers, Seattle Sutton and out and out exercise. The best part of it was ths was my first visit to this PCP, my other doctors either moved away or couldn't help me. I am thankful everyday that I picked this doctor, he may not spend alot of time with me, but the time he does spend it seems he really cares. I NEVER had a doctor like this. I guess to summarize, your doctor either knows the "tricks" or not and hopefully he can get you approved quicker. Matthew Open gastric bypass May 2005 was 416 currently 296

Hi, I have BC/BS of Illinois PPO and got approved, but I had 12 months of documentation of monthly physician visits discussing diet and exercise, 12 months plus record of regularly attending a health club and weekly weigh in records from weigh****chers (my PCP's selected diet program). I didn't have to visit a nutritionist, but that may be becuase the WW program is run by a bunch of nutrionists (I sent some background information about the WW program too). I haven't heard of anyone getting around the requirement of 12 months worth of PCP supervised diet and exercise. Everyone's insurance program differs depending on what their plan their employer has selected. Luckily, my employer is support of WLS. I was really worried that the insurance requirements would change or that they would quit covering the surgery. But, in the end I stuck it out and did my best to comply with the requirements and document that compliance thoroughly. Wish you all the best, Illini

Patty was right on! They give some people a hard time, and others not so much. It all depends on the person reviewing your file. They are human, and some are nice, and some are evil. HANG IN THERE. Fight them on it. Appeal, appeal, appeal. If you annoy thme enough they will get sick of you

D. Daniels, Hi. I, unfortunately, do not have good news for you. I have BC/BS IL PPO. I HAD HMo, but could not get my surgery approved because my medical group "had to pay for it". So I switched to PPO thinking this will be easier. That was awhile ago. I found out, at that time, that you had to complete the 12 month requirement. There were no if's, and's or but's about it. You HAVE to complete the 12 months. There must be a documented 12 month medically supervised intense diet within the last 5 years that shows that you failed to lose weight. I tried to get around it last year. Learned the hard way. Submitted to insruance to only get denied for that reason. Start the program now-you certainly won't make your deadline, but by this time next year you'll be preparing for surgery, like I am (soon, hopefully). I am waiting on that approval letter any day now. Just do the 12 months, get it over with. 12 months gives your valuable time to learn proper nutrition, healthy and unhealthy eating habits as well as boosting your self confidence, because eventually you will lose some weight. Good luck!

Meghan When did you submit your paperwork? I DID the 12 month (did a 6th month, then a two year, then a 12 month) and sent them only the 12 month. Then they called back and wanted the 6th month and the 24 month (probably to check weights). Then stalled on entering the paperwork in the computer. I finally called them and was told it was TOO MUCH paperwork? Did not get confirmation until TODAY that it was actually in the nurse's hands for review - after almost three weeks of paperwork floating back and forth!! They tell me now that my 30 days does not start until today (UGH!!!) Just wondering how long you have been waiting to hear - I will go if I have to wait 30 more days!

Patty, Keep on them. Get the name of someone there who can provide status and call them. My surgery was originally scheduled for Monday 7.25.05 and they didn't issue the approval until about 11:30 on the Friday before. I had to call them every day and remind them that my surgery was coming up. I was very polite, nice to the folks I talked to, but very persistent. Once it got in to a reviewer, since I had a surgery date that was so close, the person I got updates from was able to move my file to the top of the pile. I got the contact person I used through one of the folks in HR at work - I happened to know the person who manages our relationships with insurance carriers. She gave me the name of the contact at BC/BS for our company and I was able to use the name of my friend in HR with the insurance company (so and so told me to call you directly). That really helped keep things moving. Hang in there! Illinilady PS For anyone dealing with BC/BS - they pulled the "we never got your request for determination" thing with me too (my surgeon's office had proof of receipt of fax)...You really need to keep on top of them.

Hi Patty I actually (damn!) just called BC/BS to see if they had received any paperwork on my surgery, and apparently they have not yet. I have been trying, unsucessfully, to reach my surgeon's office this last week to find out if my stuff was even sent it. I didn't know, and can't find out-so I tried BC/BS. Great news for me! They have nothing! I am kinda upset w/the surgeon's office b/c I left messages asking to be called back and never was. I want to know if they need more info from me. I finished my program at the end of October, and it should have been submitted by Oct. 28, but it's not been submitted (according to BC/BS). What did I pay all of that money for?! Anyways, Louise from BC/BS whom I just spoke to says that once they receive the paperwork for surgery, they will send me a letter outlining the explanation of benefits within 7-10 days. Of course, I did not tell her what kind of surgery, so that may stall things! uggh!