Anybody got any recommendations on dealing with BCBS IL I have sumbitted everything once but did not have my 6 months of diet documentation. I am about to complete that and could use any info you having on getting approved. I had done everything 3 years ago and then found out I was preggers. Now I have been working at this again for 8 months and Walgreens(where I work) is requiring the 6 months its not even BCBS. Just want to make sure I get approved before my psych eval expires!

Anybody got any recommendations on dealing with BCBS IL I have sumbitted everything once but did not have my 6 months of diet documentation. I am about to complete that and could use any info you having on getting approved. I had done everything 3 years ago and then found out I was preggers. Now I have been working at this again for 8 months and Walgreens(where I work) is requiring the 6 months its not even BCBS. Just want to make sure I get approved before my psych eval expires!

I also have bcbs il and was rejected a few weeks back for VSG. At the time - they said "43775" was still investigational. I know once they saw the code - they stopped and did not even look at my packet - they rejected it within hours. I started the appeal process. They sent my appeal to their "3rd party" people last week and say it could take 60 days. Someone on another forum stated that their doctor's office got an email from bcbs (a few states one of them was il) just changed their policy to now accept VSG. I check they policy daily and as of this AM, it is still dated 9/2009 and no.

Lou

i work at a walgreens, and had my seminar last oct during open enrollment. at the seminar they said united healthcare was starting to pay for the sleeve. So I ran home and researched our ins options and bcbs il said the sleeve was investigational and uhealth would pay for it so I switched. And so, they are operating tomorrow! call and check, i know walgreens tried to say both our ins options were the same benefits wise- but they are not! they are supposed to be equal, call bcbs and tell them you will switch in open enrollment for next year and tell all you know that they provide less benefits than the other! maybe they will change their mind! doubtful, but you never know!

I have BCBS il HMO and I was approved and had surgery in May. I heard that the BCBS Il PPO will not pay. Good luck keep us posted.

Lou ... I was also denied the first time they sent it through under that code. there is another code I dont remember what it is(it is a combination of 4,8,3and 0 but I am dyslexic and dont remember which order) I will see if I can find it. When they submitted it under that number I was just denied for not having enough diet documentation. BCBS requires 3 months but Walgreens requires 6. But they did tell me that it is a covered benifit under that code so try it, maybe you wont have to appeal just resumit under the other code!

Lou ... I was also denied the first time they sent it through under that code. there is another code I dont remember what it is(it is a combination of 4,8,3and 0 but I am dyslexic and dont remember which order) I will see if I can find it. When they submitted it under that number I was just denied for not having enough diet documentation. BCBS requires 3 months but Walgreens requires 6. But they did tell me that it is a covered benifit under that code so try it, maybe you wont have to appeal just resumit under the other code!

Hi

I could not find a code with these numbers. Any luck finding it?

Lou

Any new information on codes concerning bcbs would be greatly appreciated! Could you possibly call your surgeon's office and get the code that they used?

I'm going for my surgical consult in two days June 17th.

Thanks!

The other code is 43843-A gastric restrictive surgery without bypass for the treatment of morbid obesity. It was in the list of noncovered procedures along with VSG (43775). I have BCBS North Dakota. I am in the appeal process with them. The kicker with them is that they are covering some sleeves in a pilot program, as long as you live in North Dakota and have a plan that covers WLS. Our plan covers WLS, but because I live in Oregon, not there they are saying NO, even though I have the proper coverage.

Ok ? different story ?.

I just called BCBSIL and found out my appeal was approved for sleeve gastrecomy 43775?

It took them less then a week ? it was approved on the 10th ? did not find out until I just called.

?Reason: Approval is based upon recommendation by an external peer reviewer, after consideration of the member?s individual clinical circumstances?

Now I?m doing the happy dance ?

Lou

:001_cool:

Congrats Lou... looks like I may need your help with an appeal.... if you have anything I could use I would appreciate it.

The important thing to remenber is their procedure states that 43775 (VSG) is still investigational and is not approved. So as soon as they see that ? it is stopped. Going through the process a few times ? first for the lap-band, I realized ? it only takes one thing to kick it back ? fix that and they continue until the next stop.

My advice ? have a cover letter from your primary doctor that states everything ? your BMI, if under the magic 40 ? then your ?comorbid conditions related to obesity?, your 3 month ?Supervised weight loss program? and anything else that is required. That way it?s all in front of them.

Saying that ? count on it being rejected for 43775 and an appeal is needed. This goes to a 3rd party group that will actually look at your information and in my case overturn the denail based on the same information previous given ? but this time with a cover letter from me.

Hope this helps

Lou

Lou - I am getting ready to appeal for BCBS MA for same reason. Can I get a copy of your appeal letter as a template?

Thanks.

Hi

I would be glade to give you some pointers - but not the letter. I can see it getting back to bcbsil with someone else's name on the header... not good.

Lou

check out the forums on obesity help. There are several members who have posted appeal letters on their blogs for others to use.

Lou-

Did you write a scientific letter with citations and references, or just a narrative with how you see it?

I have been trying to write a scientific one, but it is getting to be a pain to assemble the 20 references I am up to.

My appeal letter was about me. Why I think I should be approved. I stated that my diabetes was getting out of control and the next step was a pump (backed up with a letter from by PCP. I am 61 and in the process of raising my 2 grandsons (4 & 6) and would like to be healthy to enjoy them growing up and have the energy needed to keep up with them.

My though is that BCBS just read 43775 and denied. The appeal board reads what is submitted and looks at you case by case. I did have some references but I don't think that helped much.

I also searched the sites for some examples - but wound up just being myself and stating my case.

It is important that you meet the requirements stated in their policy and just need the extra push because VSG is still "investigational"

Lou