Hello all,

First post, but unfortunately I am frustrated. I know this is the holiday season, but I am sick of bl/bs of IL PPO.

I am at a 40 BMI. I found out that they denied my claim? WTF? All I read about here is how quickly bc/bs approves surgery.

The insurance guy called and said it was denied because I have no behavior modification program. Funny, the nutritionist talked to me specifically about behavior modification. I was 130 pounds and ran 5 and a half miles a day for over 20 years, and I ate well. I got hurt at work 3 years ago and gained almost 100 pounds.

Also they bc/bs guy said I have no exercise plan. Right this second I cannot exercise because of my back and knees. As soon as I lose weight, this may give me a chance to exercise. Unnfortunately, I'll never be able to run again because of a knee replacement. I can join a gym.

The last thing the insurance guy said that I have no support plan. I am going to a lap band support group if they approve this. If I have to join Weight Watchers, I will.

My doctor's medical records person is not dumb. She should know if bc/bs required that information.

I think bc/bs just wants to deny it not to have to pay for it.

Oh my husband's company is looking at other insurance companies, so I may get approved and not have that insurance any longer. I am beyond pissed.

Do any of you think I should continue to push this with my insurance company, or is a denial a blanket denial?

You're not whining, your frustrated and are trying to get answers. It's completely understandable.

The reason may be with your husband's employer. Not all BC/BS IL are the same or offer the same coverage. It greatly depends on what the employer agrees on, and in some cases, they even have their own exclusions to coverage.

Luckily my brother in law owns the company. He would never fight to keep me from getting the surgery.

I too have bcbsil and I didn't have any issues. Was approved in two weeks. Maybe it is how the doctor's office submitted the request. I had my surgery through Day One and they are well versed in the language that is needed to get approved. Maybe you might want to consider changing doctors in addition to appealing. I was never asked about any modification plans..

Same here they were on my hold that bcbsil did it was corrected that same day DAY ONE ROCKS LOL

IM MY OWN MOTIVATION

Bcbs IL I have them also and it depends on your group if u have to do the weight management. I hope eveything works in Ur favor

Bcbs is the best imo. It sounds like your drs office didnt submit all of the paperwork. My bcbs of il approved in a short amount of time.

I, too, have BCBS of IL and my approval went very quickly and very smoothly. I have to believe the doctor's office didnt submit things appropriately. My clinic has an exercise specialist and 2 nutritionists on staff. I had to meet with both of them and I believe it was for my benefit but also to help the approval process. Once it was submitted, I was approved on the first try in a couple weeks.

I would follow up with the clinic as they should be doing this for you and should know what the insurance is looking for. Please don't give up. Anything worth having is worth fighting for and your life and health are worth having!!

Try not to get discouraged!!

I, too, have BCBS of IL and my approval went very quickly and very smoothly. I have to believe the doctor's office didnt submit things appropriately. My clinic has an exercise specialist and 2 nutritionists on staff. I had to meet with both of them and I believe it was for my benefit but also to help the approval process. Once it was submitted, I was approved on the first try in a couple weeks.

I would follow up with the clinic as they should be doing this for you and should know what the insurance is looking for. Please don't give up. Anything worth having is worth fighting for and your life and health are worth having!!

Try not to get discouraged!!

.Too late,I am already discouraged. Of course all of the crap happened over the holidays. So I won't be able to get in touch with anyone until Wednesday. The other concern I have is that my husband's company is looking into changing insurance companies. So if I plan to use bc/bs to cover this, I have to do it quickly.

Day One Health is basically on Michigan Ave in Chicago. I researched it before I chose them. I really think they dropped the ball on this. It seemed like I was kind of being bum rushed because my appointment was late on Friday and everyone wanted to be off for the for the holidays. They closed the office until after New Year's Day.

I remember two things my bc/bs rep told me was I did not have a behavior modification program. That is exactly what the dietician discussed with me. I had no exercise program. That is my point. I am injured and that's what made me gain the weight. Worker's comp will not cover anymore treatments. So I am going to court for a settlement. When I receive a letter from Traveler's Insurance saying they will not cover more treatments. I will be able to go thru bc/bs to help my back. My pain management doctor says losing weight will really help my condition. I told my dietician that. She wrote something down. If that was going to be a problem, she should have talked to me about it and encourage me to at least walk 30 minutes a day.

The other thing I "think" my bc/bs rep said they need blood tests results. Has anyone had to submit a blood test to bc/bs? If not, I misunderstood him.

Someone on this board suggested I join a gym or go to the YMCA That was an excellent suggestion. I can cancel that after surgery..

Thanks to all of you that responded to my post.

Tammy, I was there on Friday to get a fill and it was very rushed but I don't believe the ball was dropped on Friday but sometime before then. My appointment was at 3:15pm and they moved it up to 1:45 pm. I'm assuming Priscilla handled the paperwork? I had to do a psych evaluation to submit to the insurance company but nothing about a modification plan. I would go back to the nutritionist and ask her to notate that your initial exercise will be walking. I would ask them to resubmit your paperwork. Who knows? It might have been the insurance approver who is not up to date on the new requirements as of February. I know there were alot of criteria prior to February in order to get approved. I hope this helps and please don't let this discourage you. I was scheduled and for days before my surgery I had to cancel to have minor heart surgery. I did have the surgery about a month and a half later.

Tammy, I was there on Friday to get a fill and it was very rushed but I don't believe the ball was dropped on Friday but sometime before then. My appointment was at 3:15pm and they moved it up to 1:45 pm. I'm assuming Priscilla handled the paperwork? I had to do a psych evaluation to submit to the insurance company but nothing about a modification plan. I would go back to the nutritionist and ask her to notate that your initial exercise will be walking. I would ask them to resubmit your paperwork. Who knows? It might have been the insurance approver who is not up to date on the new requirements as of February. I know there were alot of criteria prior to February in order to get approved. I hope this helps and please don't let this discourage you. I was scheduled and for days before my surgery I had to cancel to have minor heart surgery. I did have the surgery about a month and a half later.

Tammy, I was there on Friday to get a fill and it was very rushed but I don't believe the ball was dropped on Friday but sometime before then. My appointment was at 3:15pm and they moved it up to 1:45 pm. I'm assuming Priscilla handled the paperwork? I had to do a psych evaluation to submit to the insurance company but nothing about a modification plan. I would go back to the nutritionist and ask her to notate that your initial exercise will be walking. I would ask them to resubmit your paperwork. Who knows? It might have been the insurance approver who is not up to date on the new requirements as of February. I know there were alot of criteria prior to February in order to get approved. I hope this helps and please don't let this discourage you. I was scheduled and for days before my surgery I had to cancel to have minor heart surgery. I did have the surgery about a month and a half later.

I understand you have an injury that may prevent you from many exercises but they should still be able to give you some exercises to do. People at all levels have some sort of exercises they can do, they just need to be tailored to your ability. So they should be able to help you achieve that requirement. I know it's frustrating but try to hang in there. Also, I would keep trudging along even though your husband's insurance may change. Even if it does, the requirements are often the same or similar w/ any carrier so you will have already made progress getting things done. Also, I did the blood test but I just went to the local convenient care and it took a day or two. I had to do a psych evaluation too, so definitely ask about that. It was pretty harmless but they want to make sure you are stable to have the procedure done. I also had to go to the pulmonologist for a breathing test.

Bcbs is the best imo. It sounds like your drs office didnt submit all of the paperwork. bcbs of il approved in a short amount of time.

How right you are. I spoke to my insurance company today. They received no information from my dietician about pre and post op requirements. No modification information, and no exercise plan. My dietician discussed all of this with me. WOULD YOU BELIEVE SHE SUBMITTED NOTHING?

Also my surgeon dropped the ball. They need a letter from him as to why the lap band is a medical necessity. We discussed my high blood pressure, my borderline diabetes, my arthritis, my cholesteral, and my family history. WOULD YOU BELIEVE HE SUBMITTED NOTHING?

They also want to know that I will get counceling. I see my Psychiatrist once a month. In fact he was the one who submitted the letter saying that I was mentally prepared for the surgery. I am not sure if that is enough. They may want me to receive weekly counceling, but I forgot to ask my bc/bs rep that. :angry: :angry: :angry: :angry:

sounds like you are getting closer to resolution though

as for the counseling, i didn't have to do any ongoing. I just had to go for an evaluation to make sure I was of sound mind essentially before the procedure.

Wow they scheduled all our apt the same time i felt rushed idk will it continue to be like this or what

IM MY OWN MOTIVATION

@MsRhonda, it's not like that all of the time, but I wonder how often this occurs close to the holiday. The hours are not really client friendly either but hey, the facility is all encompassing so I won't complain...