SassyTink

Seela Hopefully, my two denials will give others the strength to fight their insurance for their surgery as well. If there is an exclusion to your policy, there is nothing you can do. My only suggestion for that is, make sure there is that exclusion. For two weeks I kept hearing, "There is an exclusion in your policy". Finally, I said,"Read it to me, because I have a copy of my policy and I don't see that exclusion". Get a copy of that exclusion. They couldn't read it to me because it wasn't there. The second issue I came across was misinformation in my file. Somewhere, after my initial denial, a biliopancreatic diversion was listed as my surgery. I still haven't received a straight answer on where that came from. My Dr was extremely thorough and documented our two visits with the Vertical Sleeve as my surgery. Both of those visits were covered by insurance. These last three weeks have been a roller coaster for me. Now, more than ever, I am positive that I am ready to proceed with the sleeve. I am nervous, scarred and a little anxious. After all, I am embarking on an exciting new way of life. If I didn't take it seriously then I wouldn't understand what this procedure is all about. It is no quick fix it is a life changer. $25,000.00 richer........thank goodness for insurance! Me

November 22, 2013 100pm.............................it is official!!!!!!! I am over the moon.

Today, Monday November 11, 900am, after 8.5 months of working on getting sleeved , I was approved. There were big mistakes made at BCBS of Illinois which lead to my denials. After nine calls to BCBS, two denials, working closely with the representative from my Bariatric Center, getting a benefit advocate from my companies Human Resources Department, and being very tenacious, it finally came through. Now, it is going to take a few days for my Dr's Office to get the approval in writing from BCBSIL but the office did call BCBSIL to get the approval. I have to go to the pre-op class and then I am set. My advise to anyone that is denied VSG Surgery is to make sure that they get a copy of their policy and the exclusions. 8.5 months ago I was approved to begin the program so this denial came out of the blue. My file became more complicated after the denials. Erroneous information had been added to my file that were not part of my policy. Unfortunately the representatives at BCBSIL read the incorrect information and kept telling me the procedure was denied. Thank you for all of your support everyone. I guess working this hard to get approved really makes me understand the importance of this surgery for me. It gives me, and everyone else that suffers from obesity a chance to have a wonderful, happy, healthy, longer life. Two weeks ago my hope for a healthier future was dashed. Today I am smiling from ear to ear. Again.......it is a go!

P.S. I have crossed my "T's" and dotted my "I's" as far as following the guideline BCBS sent me initially. I also have, osteoarthritis of my right hip, severe sleep apnea and am pre-diabetic. The co-morbidities are there. We shall see what new reason appears to deny me.

The misinformation continues! I have been on a roller coaster all week. I called BCBS of Illinois Monday and was told my surgery request was denied, once again. The reason, an exclusion in my policy. I went on line, found my policy on my company website, scrutinized that policy, came to the conclusion that BCBS is mistaken. Next, I call my companies benefits department and opened a "Ticket" with an employee advocate. She read the policy as well as the exclusions and told me bariatric surgery prior to 2010 was not covered. It is covered now with the inclusion of using a Blue Distinction Hospital. That could be the issue. The person at BCBS might not be reading the entire policy. With this new information I called BCBS on Wednesday. I got a really terrific woman named Donna. After putting me on hold for 10 minutes Donna told me that the surgery I wanted should not be denied. It seems there was a problem with reading my entire policy. It says, "Bariatric Surgery will not not be covered" next line, "Unless the Provider is a Blue Distinction Hospital of Excellence" I guess the person determining my surgery request couldn't bother reading the next line of the policy!!! Donna told me she would reopen my request and give it 48hrs. Now it is Friday. I called BCBS, another denial. They had a biliopancreatic diversion switch as my procedure and not the vertical sleeve. Some idiot at BCBS had assumed that was the procedure without looking at my Dr's notes and the entire packet sent to them. Mistake number 2. Ashley at BCBS was dumbstruck at the 50 pages of notes in my file at BCBS. She apologized and told me about this procedure and that is not covered in my policy. I told her my physicians office doesn't even do the procedure. This procedure was never discussed and I need someone to pay attention at BCBS. I told her I had a benefits advocate from my company on it and I wanted the rectified! She promised me she would walk my file through the powers that be and call me back. At 250pm, Friday, she was going home at 500pm Central Time, she called me to tell me my file was reopened, the benefit was hi lighted in my policy, and the correct procedure was added to my surgery request. Her final words were, "There is no reason for a denial, I am so sorry." It takes 48 hours for a re-opened file to get an approval. I will be on the phone Monday morning! I called my Dr's Office and they are flabbergasted. They have done everything right, it is not their fault. They have assured me they will get me in for surgery as fast as they can after the approval. Wow, I can't believe I working this hard to cut 2/3's of my tummy off! More drama to come............

Tbird49 I do not have the exclusion to my policy, somebody at BCBS was not being very thorough. I will be approved, there was never a reason to be denied and that is why I was in such shock. I am still weary until I get the APPROVED and date from my Dr.

Guess what? I was on the phone at 0800 to the Bariatric Center. The insurance coordinator was in and told me that she got an okay from BCBS on March 21 2013. The gastric sleeve procedure was covered under my plan if all of the pre-surgical requirements were accomplished. She couldn't believe that I was denied because of an exclusion in my policy. This was news to my Dr's office. She promised she would call BCBS and find out what is going on. 2 hours later I couldn't wait any longer and called BCBS once again. I got a really knowledgeable woman on the phone that had quite a bit of empathy for me. What I did tell her was I looked up my policy on my company website and it explains bariatric surgery as part of my plan. I wanted an answer to what my policy excluded as far as bariatric surgery. She put me on hold for at least 10 minutes. When she returned to the call she said, "THERE IS NOT AN EXCLUSION ON YOUR POLICY REGARDING BARIATRIC SURGERY, IT WAS AN ERROR THAT THE DENIAL LETTER WENT OUT TO YOU." She said, she could not tell me that my surgery was approved but there is not an exclusion. She told me that she would give my file to her manager to be expedited through the system because of the error. Now, let's see how fast everybody steps up to the plate to help me get that November date. I am so relieved. Thank you everyone for all of your support and kind words. ME

Right now I am so devastated I can barely type. My process began on March 20 2013, when I notified BCBS of Illinois concerning Bariatric Surgery. Below is a copy of the correspondence: 03/20/2013 18:44:00 -- Member Question: Hello Unfortunately, at this time I am looking into Bariatric Surgery at the recommendation of my internist. We have a Blue Distinction Bariatric Center in Portland. What are the different steps that Blue Cross requires, under my plan for this surgery. Response: Bariatric Surgery 03/21/2013 15:12:31 - HCSC Response: Hi Patrice, Surgical treatment of morbid obesity may be considered eligible for coverage when all of the physical, clinical and psychological indications are documented according to Blue Cross Blue Shield of Illinois current medical policy. A letter of support and/or explanation is helpful but alone will not be considered sufficient documentation to make a medical necessity determination. We are not in a position to consider the request for surgical treatment of morbid obesity due to the lack of available medical documentation to determine medical necessity based on Blue Cross Blue Shield of Illinois medical policy. The following documented clinical information is necessary for further review. For a member to be considered eligible for benefit coverage of bariatric surgery to treat morbid obesity, the member must meet the following two criteria: 1. Diagnosis of morbid obesity, defined as a: - Body mass index (BMI) equal to or greater than 40 kg/meter (* see guidelines below for BMI calculation); OR - BMI equal to or greater than 35kg/meters with at least two (2) of the following comorbid conditions related to obesity that have not responded to maximum medical management and that are generally expected to be reversed or improved by bariatric treatment: o Hypertension, OR o Dyslipidemia, OR o Diabetes mellitus, OR o Coronary heart disease, OR o sleep apnea, OR o Osteoarthritis; AND 2. Documentation from the requesting surgical program that: - Growth is completed (generally, growth is considered completed by 18 years of age); AND - Documentation from the surgeon attesting that the patient has been educated in and understands the post-operative regimen, which should include ALL of the following components: 1. Nutrition program, which may include a very low calorie diet or a recognized commercial diet-based weight loss program; AND 2. Behavior modification or behavioral health interventions; AND 3. Counseling and instruction on exercise and increased physical activity; AND 4. Ongoing support for lifestyle changes to make and maintain appropriate choices that will reduce health risk factors and improve overall health; AND - Patient has completed an evaluation by a licensed professional counselor, psychologist or psychiatrist within the 12 months preceding the request for surgery. This evaluation should document: 1. The absence of significant psychopathology that would hinder the ability of an individual to understand the procedure and comply with medical/surgical recommendations, AND 2. The absence of any psychological comorbidity that could contribute to weight mismanagement or a diagnosed eating disorder, AND 3. The patient's willingness to comply with preoperative and postoperative treatment plans. The member and their physician(s) are urged to review the full text of the Blue Cross Blue Shield Illinois (BCBSIL) medical policy on this subject on the BCBSIL Website at www.bcbsil.com. Choose the "provider" link at the top of the Website and select medical policies: Surgery for Morbid Obesity (search by policy title). If you any further questions or concerns, please contact our customer service department at the toll-free number on the back of your Blue Cross Blue Shield identification card or via the Message Center on Blue Access for Members. Sincerely, Cheryl M. Blue Cross Blue Shield Illinois Customer Service Center For the last six months I have seen the Bariatric Centers Dr's, nutritionist, physical therapist, psychologist and 80% of every appointment was covered by my policy. I have pain my 1500.00 out of pocket expenses and ready to go. Today I found out that my insurance policy has an exemption on Bariatric Surgery. WHAT?????? The insurance company gave me the info above and paid all of the pre surgery visits. I assumed the Dr's office did their job, Submit an electronic Eligibility & Benefits Inquiry (ANSI 270 transaction) to BCBSIL through your preferred online vendor portal. Now I am left disappointed and totally depressed. I just can't understand how this happens.

YOU ARE NOT GOING TO BELIEVE THIS. My policy does not have an exclusion for bariatric surgery. BCBS of Illinois admitted that my denial was a MISTAKE. BCBS is now going over my file and an approval should be coming within 24 hrs. They apologized for the error, will re-evaluate my request for surgery and hopefully get back to me quickly. The Dr's office has also been informed by me that I want my surgery scheduled as soon as they get the approval. ENOUGH IS ENOUGH! WHAT A JOKE. It looks like the last 24 hrs of torture were a character building experience. I don't have the approval yet, but am confident it should be forthcoming. Prayers really do work. I thank everyone of you who sympathized with me. Your responses of support were really helpful. Again, sincerely, I thank you. Me

I spoke to the Bariatric Center again this morning. Apparently, they have a letter dated March 20, 2013 from BCBS giving the okay for the Bariatric process. The Dr's office did everything 100% correctly according to their notes. Now, we play the blame game as to who is in the right here. Is the insurance company game playing or is the Dr's office? I will soon find out. My intuition is the Dr's office did everything by the book and the insurance company screwed up. Why would BCBS pay 6 months of pre bariatric surgery appointments if I wasn't covered? The plot thickens. I am going to have my surgery this month.......regardless of who screwed up. They have to make this right. Beware!!

Thank you for the words of encouragement girls. I have just begun the fight. I will find out why the Bariatric Center did not check with my insurance 6 months ago. They took all of my insurance information before I even got my first appointment. What did the insurance say at that time? Why did BCBS pay for all of the appointments if my policy has an exclusion? Why did BCBS send me a list of what I have to do? I will seek reimbursement of the $1500.00 out of pocket expense (Deductible), or I will request a discount to make this surgery happen. They need to make this affordable or me. If this office does not rectify this situation I will get a Personal Injury Attorney involved. This entire 6 months has been a scam if they don't fix the situation. They do not know who they are dealing with. I am not a passive, poor me, kind of gal. I am assertive and have tried my tears and am ready to fight. The problem I am having is being let down by people I trusted.

Wags, the first I heard of the exclusion was today on the phone. I called to find out if my paperwork had been submitted by the Dr's office. My last appointment was October 23 so I was trying to get that surgery date. I have called the Bariatric Center twice today and they have not called back. Somebody has to explain to me what happened. The Bariatric Center should have verified my policy 6 months ago. I can't get the approval for surgery it has to come from the Provider. I can't stop crying. I have to get my hip replaced and can't get it replaced until I lose this weight. The hip pain is excruciating, and now mentally I am destroyed.

BCBS said there has always been an exclusion on my policy. "An exclusion is an exclusion and can not be covered!!" The reply I got from them six months ago was generic, per the BCBS associate I spoke to. The Dr's office also dropped the ball. They should have done the eligibility inquiry like they were supposed to. It seems like the insurance and the Dr's office were remiss. I did everything by the book. This is awful. I just can't wrap my head around this. So sad, I wanted this so badly.

I have been drinking a Protein shake for Breakfast and lunch in lieu of food, and a light meal for dinner for the last two weeks. I wanted to drop as many pounds as I can for my final weigh in and to help me prepare for the liquid pre-op diet that is fast approaching. I am getting used to the Protein shakes and they seem to give me tons of energy. As anyone else experienced this?

Oh how wonderful to be referred to as a "Wee little thing." This helpful man would have probably walked on by 67 pounds ago, but just couldn't resist a petite little damsel in distress. I love this!

Wow, what a transformation. You look so happy and you should be!

mizzzmoka me too!! I see the Surgeon, PT, Dietician on October 23 for my last visit and to sign consent forms. I am so excited!!! Let's hope we get a fast approval and scheduled for mid-Nov surgery. Keep me posted.

ejsfanatic- See if the therapy company can let you try the nose pillow. It is small and fits nicely below your nose and above your lip. My brand is ResMed. They also gave me two pink strap covers to put on the plastic straps that touch your cheeks. The machine is remarkably quiet. I feel so weird saying I love my C-Pap machine but I really do! The crazy dreams make it well worth it!

I also was diagnosed with Severe sleep Apnea. I hadn't a clue when I walked into the hospital 5 months ago to have my sleep study as part of my pre-requisite for bariatric surgery. After an hour into the sleep study, I was awakened, put on a C-Pap machine and slept through the rest of the night. 2 days later I got my very own C-Pap machine and have been a happy girl ever since. It has changed my life. I was given a ResMed and a small nose pillow instead of a face mask. It is comfortable and real easy to get used to. I adjusted to the machine the very first night. In fact, I have the most vivid dreams now. I had no iea what it felt like to sleep well. Now, I have tons of energy, and feel well rested. It never entered my mind that I had sleep apnea. I just assumed I was exhausted from the normal work of life. My advise is DO NOT GIVE IN AND TAKE THE MASK OFF. Roll over and go back to sleep because eventually you will love it! I promise. Give the C-Pap time, it could save your life as long as you have sleep apnea.

Embrace the 6 months. Since I started the process I have found out that I have quite a few health issues. I was clueless. When I went for my overnight sleep test I was hoping I had a little sleep apnea so I would have another comorbidity to help me through with the insurance requirements. Boy was I shocked at my number 55 and diagnosis of SEVERE SLEEP APNEA. My blood tests came back with borderline diabetic. I now really understand the importance of this surgery. It is a life changer and I am now educated as to why I must have it. You will learn a lot about yourself. The six months is in place for a reason. Even though I am at 5 month 19 days (Who is counting) I would do it again. Take advantage of all of the medical professional that you will encounter. Ask questions!

Wow......it is like you are still you but miniature! Keep up with whatever you are doing.

I am sorry you have to go through this. Look on the positives, you are getting into really good shape for your surgery. Your liver is going to shrink quite a bit if you are sticking to the Protein first diet. BCBS was really easy to work with concerning approval and payments. The good news is they are very vast fast in getting the approvals to your Dr's office once it is submitted. There is light at the end of the tunnel. Patient endurance, you can do it.

It is happening to me right now. I am switching from BCBS of Illinois to AETNA on January 1, 2014. (Not by choice) My Dr has been notified by me that it is imperative I have my surgery ASAP. I started my journey in April so I am six months invested October 23. The bariatric office informed me that my policy is very clear on it's requirements. No surgery until six months of a weight management program!! You need to ask your Dr. what your policy requires. Regardless of the offices requirements, find out your current insurance requirements. If it doesn't include a six months weight management program then ask your Dr. to wave their requirements. Also, my BCBS would only allow certain "Blue Excellence" hospitals. That is another thing to look into whether your current Dr's hospital is part of that network.

I am coming out!! No more hiding. I changed my profile picture from Tinker Bell to ME. My name is Patrice and I hope to get my surgery date on October 23 when I have my last appointment with my surgeon. I am looking at mid November for my sleeve. Love the idea of us Novembers sticking together for our journey!

If you share your "Double Stuffed Cookie Nectar Syntrax" with me I will share some of this delicious Gold Standard Whey Milk Chocolate Protein that I just whipped up. That is what friends are for!