BC/BS of IL SUCKS

sallyone
on 5/31/07 8:26 am - DIberville, MS

Well I have verbally been denied (letter went out today). BC/BS states that my 6 month diet notes look too generic, they all look the same and they dont have enough information in them. Such as when I gained or stayed the same in weight, what specifically did my doctor tell me to do. Well my doctor didnt tell me to do anything, she thought doing the 6 month diet was a bunch of crap. It seems that my case is going into a Peer to Peer review... Surgeon with Insurance Doctor. I dont know what that is or how worried I should be. The insurance lady said to hold off doing anything until a decision is made from that. I have an appt with my PCP (who did my diet) and I am going to discuss it with her tomorrow. The insurance lady sounded like if the Peer to Peer Review goes bad and I am still denied, I will have to do my 6 month diet again and have it documented more in depth.... this cant be true can it. Our Insurance renews again in December... I will never have it all done and surgery before they change it and maybe drop the coverage. HELP... I think now I need moral support and any advise you can give. Thanks Susan

Paula H.
on 5/31/07 10:37 am - Duncan, OK

Susan, I hear you. I too am worried about our insurance. It has approved RNY rapidly and easier in the past for friends. I am worried about it dropping the coverage in the future. Perhaps that is the reason why they want me to do a "year long" diet. Good luck, Paula

sallyone
on 5/31/07 10:44 am - DIberville, MS

RNY on 07/31/07

I sure do hope they dont change or cancel insurance before you get done with your diet. I think insurance companies do this crap on purpose, just to make people quit so they dont have to pay... GOOD LUCK

TropiGal R.
on 6/1/07 12:28 am - Milwaukee, WI

RNY on 06/06/07

Sally, Gary has some info about peer to peer erview in the upper area of this forum. I was really worried about my three month diet notes-and kept my own and had trge doctor sign off on them each month. These were sent in along with the doctor's official notes. My surgeon's office said this was a really good idea. My PCP alos thought the diet was a waste of time and did it just to humor the insurance comapny. It took my insurance company 25 days, but they eventually approved me and I am having surgery in 5 days! I am copying a Sample of what I sent. I am not sure if you still have the opportunity to have your PCP document more accutratly or not.

Monthly Progress Notes: Physician Supervised Weight Loss Program

Patient:_____________ Date of Birth: (Last Name) (First Name)

Address:__ (Street) (City, State) (Zip Code)

Height: 65” (5’5”) Start Weight: 275.5________ Goal Weight:___144________ Age:_ 42__

Diet Description :______Low Calorie/Low Fat________________________

Diet Start Date: January 9, 2007

Initial Consultation: Patient met with Dr. XXXXX on January 9, 2007 to discuss a low calorie/low fat diet as well as an exercise program designed for weight loss. Patient will follow the Weigh****chers food plan and exercise at least 3 times per week. Exercise will consist of walking on a treadmill or outdoors or working out at Curves-for a minimum of 30 minutes per session. Patient will meet with the doctor at least once a month to discuss nutrition and diet as well as behavioral changes needed reinforce healthy eating and exercise habits. Patient will be weighed at each appointment with the physician.

Weight loss medications are Not recommended due to Lisa’s hypertension.

Monthly Progress

Completion of Month 1 Date: 2/9/07 Weight: 274 Total Weight Loss: -1.5lb

Notes: Discussed food plan: following Weigh****chers (a low calorie /low fat plan.) Staying under 1200 calories/day.

Discussed exercise program: Lisa is walking for 30 minutes 3-4 times a week.

Discussed behavioral changes: Stop drinking carbonated/caffeinated beverages, no eating after 7:00PM, no fast food, keeping a food journal.

________________ ____________________________

(Physician Signature) (Date)

Completion of Month 2 Date: 3/9/07 Weight: 275.4 Total Weight Loss: -.01

Notes: Discussed food plan: continues to follow the low calorie/low fat food plan, staying under 1200 calories/day. Lisa has increased her consumption of fruits and vegetables.

Discussed exercise program: Lisa continues walking for 30 minutes 3-4 times a week.

Discussed behavioral changes: Same as above, but also cut out late afternoon snacking.

_________________ ___________________________

(Physician Signature) (Date)

Completion of Month 3 Date: 4/9/07 Weight: Total Weight Loss:

Notes: Discussed food plan: continues to follow the low calorie /low fat food plan, staying under 1200 calories/day. Lisa has increased her fiber intake.

Discussed exercise program: Lisa had to discontinue exercise for a few weeks due to a back injury. She then resumed walking for 20 minutes 3-4 times a week.

Discussed behavioral changes: Same as above, but also increased water consumption.

Lisa has been compliant with the three month physician supervised weight loss plan.

Gastric Bypass surgery (Roux-en-Y) is recommended for health reasons.

______ ______________________

(Physician Signature) (Date)

Lisa R.

sallyone
on 6/1/07 3:40 pm - DIberville, MS

RNY on 07/31/07

Hi Lisa.. Thanks.. I checked out the information on the Peer to Peer Review at the top. Funny thing is the insurance company said that my surgeons office asked for it.. but the surgeons office told me no they did not... mmmmm I went to see my PCP today and she is going to write a letter or somthing, but I dont think that will work, but we will see. It looks like I am starting my 6 month diet over...arrgghhh Lisa, my forms were pretty close to what you used... but my insurance is being a butt about it. The insurance person at the surgeons office even made copies of my form (after taking out my info) and is using that with their patients now... LOL Thanks alot,

TropiGal R.
on 6/1/07 11:33 pm - Milwaukee, WI

RNY on 06/06/07

Susan, I am so sorry..I really hope the peer to peer review goes well. I hated the diet-and I only had to do three months. Best of luck-and keep us posted on the progress! Hugs, Lisa

Lisa R.

coolrayswife
on 6/2/07 2:32 am - Clay, KY

RNY on 09/26/07

Susan, Hang in there girl and don't give up. That's why the insurance companies require so much, because half of us think its too much and give up. I guess this is what they call jumping through hoops.

Maybe your pcp can readvise on your previous 6 month diet and resend it. I'm right there with ya. My papers were sent in on May 18th and we still haven't heard anything. Did you call your insurance company yourself? Also did you lose on your 6 month diet? We're here for ya and will be praying for you. Thanks, Tammy

1st consult/surgery/current/goal
293/ 264/ 155/145

sallyone
on 6/2/07 3:18 am - DIberville, MS

RNY on 07/31/07

Thanks Tammy, I only lost a total of around 5 pounds on my 6 month diet. My PCP is going to send some more stuff in. Just in case that dosent work they are starting my 6 month diet OVER...arrgghhh I have spoken to the insurance company a few times in the last 3 days... LOL I will keep trying and see what happens. I hope you hear something soon on your papers.

BC/BS of IL SUCKS

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BC/BS of IL SUCKS