Jump to content
×
Are you looking for the BariatricPal Store? Go now!

Blue Cross Blue Shield of Illinois PPO



Recommended Posts

Does anyone have the BCBS of IL PPO? I am really confused with this whole process. I met with my surgeon back in May. Then he told me that he wouldn't see me until one month before surgery. His office already had me do some testing, but it's my understanding that I am required to do the 6 months medically supervised diet. Can someone clarify this for me?

Share this post


Link to post
Share on other sites

I too have BCBSIL and yes they do require 6 months of medically supervised weight loss within the last 24 months. Along with that you have your psych eval and nutritional education (I did thru my PCP). I started this in January and at that time it was only 3 month but that changed in March :( They also require your BMI to be over 40 without co-morbidities or 35+ with 2 co-morbidities.

Once my 6 months was over my file was submitted and in 1 week I had an answer that they needed additional information. The additional information was faxed over by me on 8/17 and again by my surgeon's office on 8/18 and I received my approval on 8/25/11 but I did have to call to get the verbal approval.

I hope this information helps...Let me know if you have any other questions I can help out with. I studied the insurance coverage and requirements so there were NO surprises!!!

Share this post


Link to post
Share on other sites

Monica, has your surgery been scheduled yet??? I have BCBSIL... and I'm going through the Bariatric Center at Little Company of Mary... I was hoping to have my surgery during the holiday break (I teach high school Chemistry), but my pt. coord. thinks that's a lofty goal since my final appt w/ my wt loss spec isn't until dec. 10 (i think).. My break starts on the 17th... I already met w/ my surgeon (Dr. Gerald Cahill) and I'm going for an appt. w/ a pulmonologist this afternoon..

So, your post gives me hope that I can possible get a date for the end of year.. I hope so!!! LOL..

Blessings and good thoughts to you!!!

I too have BCBSIL and yes they do require 6 months of medically supervised weight loss within the last 24 months. Along with that you have your psych eval and nutritional education (I did thru my PCP). I started this in January and at that time it was only 3 month but that changed in March :( They also require your BMI to be over 40 without co-morbidities or 35+ with 2 co-morbidities.

Once my 6 months was over my file was submitted and in 1 week I had an answer that they needed additional information. The additional information was faxed over by me on 8/17 and again by my surgeon's office on 8/18 and I received my approval on 8/25/11 but I did have to call to get the verbal approval.

I hope this information helps...Let me know if you have any other questions I can help out with. I studied the insurance coverage and requirements so there were NO surprises!!!

Share this post


Link to post
Share on other sites

My surgery date is September 28. When I talked to the patient coordinator she said they were scheduling in October but when I got the call it was September 28. It all depends how far out your surgeon schedules.

Share this post


Link to post
Share on other sites

What they told you about the BCBS PPO approach is true. You have to be on a six month medically supervised diet before the surgery. You might lose weight, not lose weight, gain weight...there is no requirement other than the surgeon's office being able to say that you were on "a six month medically supervised diet". Then BCBS of Illinois will pay for the surgery. I don't want to wait six months and having any of the surgeries (lap band, gastric sleeve plication or gastric bypass) are less than half the cost in the Mexican hospitals. Plus, the Mexican doctors have more experience with the procedures. They have all done more and have been doing them longer. That is why I decided to go to Mexico and to pay for the surgery myself. Clinic in Chicago wanted $13K for the lapband vs. 4995 in Hospital Angeles Tijuana. They don't even offer the gastric plication surgery here yet. So, I am off to Mexico for surgery at the end of the month. I should be 60 pounds thinner before BCBS would even let me do anything.

Share this post


Link to post
Share on other sites

I have BCBSIL PPO and work for them. I was told specifically that 6 months medically supervised weight loss was 6 months of visits with your physician where you discuss your weight, what you are doing to lose during your 6 months, exercise/diet plan etc. I have heard of one person submitting 6 months of nutritionist visits and being approved. My Dr filled out a form my surgeon's office required each month and only submitted once they had all of those forms in hand. I was told specifically also that a weight watchers booklet showing 6 months of weigh ins doesn't count. Now, if you have discussed your weight and what you were doing to lose 6 times over 24 months your doctor could say you have met that requirement.

Here is a link directly to the medical policy -

http://medicalpolicy.hcsc.net/medicalpolicy/home?ctype=POLICY&cat=Surgery&path=/templatedata/medpolicies/POLICY/data/SURGERY/SUR716.003_2011-03-15#hlink

The statement below is pretty clear -

Documentation of active participation in a comprehensive, non-surgical program of weight reduction for at least six (6) months, occurring within the twenty-four (24) months prior to the proposed surgery.

Share this post


Link to post
Share on other sites

Monica you are right on point. You posted the medical policy to a T. I have a quick question I've been seeing my PCP for medical Weight Management....Did you see a nutritionist or did you receive nutritional counseling from your pcp?

Share this post


Link to post
Share on other sites

I did the nutrition with my PCP also and he had noted everything we talked about in his progress notes. So when I turned in my 6 months of notes everything was in there. Although we had to fax some pages twice I did get the approval 5 days after the 2nd fax.

Share this post


Link to post
Share on other sites

I have bcbs but it's trs TX. My medical policy reads the same about the documentation on non surgical weight management for 6 months. I was denied the first time with my Weight Watchers documentation but appealed it with medical review. I won. Weight watchers IS a nonsurigcal program of weight reduction. It took one day after medical review to be approved. My doctor was ready for surgery the next week.

Share this post


Link to post
Share on other sites

Let you in on a secret - IL TX NM and OK are all under Health Care Service Corporation so they would be similar med policies :rolleyes: That is so awesome you got approved with weight watchers! I have always heard they wouldn't.

I have bcbs but it's trs TX. My medical policy reads the same about the documentation on non surgical weight management for 6 months. I was denied the first time with my Weight Watchers documentation but appealed it with medical review. I won. Weight watchers IS a nonsurigcal program of weight reduction. It took one day after medical review to be approved. My doctor was ready for surgery the next week.

Share this post


Link to post
Share on other sites

Thanks! It was an uphill fight but the policy does not say physician supervised. That's just something they like to say when they want to deny you. They even called my pcp and tried to get her to say I hadn't been compliant with Weight watchers. Crazy!

Share this post


Link to post
Share on other sites

The key is to fight. I to work for a major insurance company but I am also a member and I understand the importance of being insistence and standing firm. I'm getting excited and ready

Share this post


Link to post
Share on other sites

Congrats Phat for being proactive

Share this post


Link to post
Share on other sites

Create an account or sign in to comment

You need to be a member in order to leave a comment

Create an account

Sign up for a new account in our community. It's easy!

Register a new account

Sign in

Already have an account? Sign in here.

Sign In Now

  • Trending Products

  • Trending Topics

  • Recent Status Updates

    • Prdgrdma

      So I guess after gastric bypass surgery, I cant eat flock chips because they are fried???  They sell them on here so I thought I could have them. So high in protein and no carbs.  They don't bother me at all.  Help. 
      · 1 reply
      1. NickelChip

        It's possible for a very high fat meal to cause dumping in some (30% or so) gastric bypass patients, although it's more likely to be triggered by high sugar, or by the high fat/high sugar combo (think ice cream, donuts). Dietitians will tell you to never do anything that isn't 100% healthy ever again. Realistically, you should aim for a good balance of protein, carbs, and fat each day. Should you eat fried foods every day? No. Is it possible they will make you sick? Maybe. Is it okay to eat some to see what happens and have them for a treat every now and again? Yes.

    • NovelTee

      I'm not at all hungry on this liquid pre-op diet, but I miss the sensation of chewing. It's been about two weeks––surgery is in two days––and I can't imagine how I'll feel a couple of weeks post-op. Tonight, I randomly stumbled upon a mukbang channel on YouTube, and it was strangely soothing... is it just me, or is this a thing? 
      · 1 reply
      1. NickelChip

        I actually watched cooking shows during my pre-op, like Great British Baking Show. It was a little bizarre, but didn't make me hungry. I think it was also soothing in a way.

    • Clueless_girl

      How do you figure out what your ideal weight should be? I've had a figure in my head for years, but after 3 mths of recovery I'm already almost there. So maybe my goal should be lower?
      · 3 replies
      1. NickelChip

        Well, there is actually a formula for "Ideal Body Weight" and you can use a calculator to figure it out for you. This one also does an adjusted weight for a person who starts out overweight or obese. https://www.mdcalc.com/calc/68/ideal-body-weight-adjusted-body-weight

        I would use that as a starting point, and then just see how you feel as you lose. How you look and feel is more important than a number.

      2. Clueless_girl

        I did find different calculators but I couldn't find any that accounted for body frame. But you're right, it is just a number. It was just disheartening to see that although I lost 60% of my excess weight, it's still not in the "normal/healthy" range..

      3. NickelChip

        I think it's important to remember that the weight charts and BMI ranges were developed a very long time ago and only intended to be applied to people who have never been overweight or obese. Those numbers aren't for us. When you are larger, especially for a long time, your body develops extra bone to support the weight. Your organs get a little bigger to handle the extra mass. Your entire infrastructure increases so you can support and function with the extra weight. That doesn't all go away just because you burn off the excess fat. If you still had a pair of jeans from your skinniest point in life and then lost weight to get to the exact number on the scale you were when those jeans fit you, chances are they would be a little baggy now because you would actually be thinner than you were, even though the scale and the BMI chart disagree. When in doubt, listen to the jeans, not the scale!

    • Aunty Mamo

      Tomorrow marks two weeks since surgery day and while I'm feeling remarkably well and going about just about every normal activity, I did wind up with a surface abscess on on of my incision sights and was put on an antibiotic that made me so impacted that it took me more than two hours to eliminate yesterday and scared the hell out of me. Now there's Miralax in all my beverages that aren't Smooth Move tea. I cannot experience that again. I shouldn't have to take Ativan to go to the lady's. I really looking forward to my body getting with the program again. 
      I'm in day three of the "puree" stage of eating and despite the strange textures, all of the savory flavors seem decadent. 
      I timed this surgery so that I'd be recovering during my spring break. That was a good plan. Today is a state holiday and the final day of break. I feel really strong to return to school tomorrow. 
      · 0 replies
      1. This update has no replies.
    • BeanitoDiego

      Now that I'm in maintenance mode, I'm getting a into a routine for my meals. Every day, I start out with 8-16 ounces of water, and then a proffee, which I have come to look forward to even the night before. My proffees are simply a black coffee with a protein powder added. There are three products that I cycle through: Premier Vanilla, Orgain Vanilla, and Dymatize Vanilla.
      For second breakfast on workdays, I will have a low-fat yogurt with two tablespoons of PBFit and two teaspoons of no sugar added dried cherries. I will have ingested 35-45 grams of protein at this point between the two breakfasts, with 250-285 calories, and about 20 carbs.
      For second breakfast on non-workdays, I will prepare two servings of plain, instant oatmeal with a tablespoon of an olive oil-based spread. This means I will have had 34 grams of protein, 365 calories, and 38 carbs. Non-workdays are when I am being very active with training sessions, so I allow myself more carbohydrate fuel.
      Snacks on any day are always mixed nuts, even when I am travelling. I will have 0.2 cups of a blend that I make myself. It consists of dry roasted peanuts, cashews, pumpkin seeds, sunflower seeds, pistachios, and Brazil nuts. This is 5 grams of protein, 163 calories, and 7 carbs.
      Breakfast and snacks have been the easiest to nail down. Lunch and dinner have more variables, and I prepare enough for leftovers. I concentrate on protein first, and then add vegetables. Typically tempeh, tofu, or Field Roast products with roasted or sautéed vegetables. Today, I will be eating leftovers from last night. Two ounces of tempeh with four ounces of roasted vegetables that consist of red and yellow sweet peppers, sweet potatoes, small purple potatoes, zucchini, and carrots. I will add a tablespoon of olive oil-based spread, break up 3 walnuts to sprinkle of top, and garnish with two tablespoons of grated Parmesan cheese. This particular meal will be 19 grams of protein, 377 calories, and 28 grams of carbs. Bear in mind that I do eat more carbs when I am not working, and I focus on ingesting healthy carbs instead of breads/crackers/chips/crisps.
      It's a helluva journey and I'm thankful to be on it!
       
      · 0 replies
      1. This update has no replies.
  • Recent Topics

  • Hot Products

  • Sign Up For
    Our Newsletter

    Follow us for the latest news
    and special product offers!
  • Together, we have lost...
      lbs

    PatchAid Vitamin Patches

    ×