My Insurance Story - Blue Cross Blue Shield Of Illinois

[bakawaka 59]

I wanted to share the story about why I am a self-pay. I have a BMI of 35. This places me in the Class I obesity category. I have two co-morbidities: high blood pressure and high cholesterol plus heavy snoring (not yet apnea). My insurer, Blue Cross Blue Shield of Illinois, denied coverage on the grounds that my surgery is not "medically necessary." Does anyone know what medically necessary means? My primary care physician and my WLS surgeon view it as medically necessary. The insurance denial is not stopping me. I want better health. I do not have a specific goal weight, though I do have as goals getting off of cholesterol and blood pressure medication. Has anyone had a similar BMI and similar conditions but gotten covered by insurance? It is an interesting thought that my self-pay surgery will not only benefit me in terms of health but also my insurance company.

[skye 46]

I too am blue cross BMW 30 no co morbidities ans I was approved also in Illinois who is you Dr

[dbritt 4]

I am also with BCBS of IL. Did you have to do the 6 month deal where you talk with a dietician monthly? I am in my 2nd or 3rd month of it now?

I am scared to death that I will go through this only to be denied. My BMI is 49 though. The office keeps telling me that I will know front the begining if they are going to deny me.

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[bakawaka 59]

BCBS of IL stated that the VSG procedure is "not medically necessary" and thus denied my claim. I am self-pay. I have a BMI of 35.5 + high blood pressure + high cholesterol. My BMI falls into Class 1 Obesity, not morbid obesity. I view the procedure as medically necessary. That's why I am going to pay for the procedure myself. I am disappointed with BCBS' decision. I am not an insurance expert. It seems reasonable to me that your BMI would motivate BCBS to say that you procedure is medically necessary. Apparently, our employers set conditions for the insurers. I want better health and am hoping that VSG surgery will help me lower my blood pressure and lower my "bad" cholesterol. I wish you the greatest success!

[Silly Phylly 20]

About to head down the old insurance road with BCBS of Alabama. I have a 37+ BMI, on metformin, diagnosed fatty liver, asthma, back issues etc... If I am not medically necessary I just don't know! Like one of the other posts stated, I can't imagine going through all the preliminaries only to be denied. I will be crushed! Unsure at this time if self-pay will even be an option.

[Mz Need da Sleeve 17]

Have your surgeon appeal. They usually approve after that.

[lessofmeismore 1,405]

Bcbs denied me too. I have high blood pressure, diabetes, sleep apnea, deteriorated discs in my spine and a bmi if 40. They said it wasn't * medically neccesary* as well for me. I never won my appeal and I did self pay. I wish you the best.

[Rootman 1,101]

I had a BMI of 50 with a few co-morbidities. I was NOT willing to go through the crap that the insurance company had put others through in my company. ONE of them made it and had the surgery, two others I heard of gave up or were disallowed because they lost enough weight to drop below a BMI of 40 and there the surgery was no longer "medically necessary". I was sick, getting sicker and could see that I was slowly killing myself - or perhaps not even slowly as I was having breathing problems and feeling strain on my heart.

I do not endorse going self pay in Mexico even though I did it myself, there is a much greater risk of issues doing it that way. But if you are in the same boat I am in then all I can say is GO FOR IT. The operation was the single best thing that I have done for myself health wise in my entire life.

[Ljp 157]

BCBS of IL stated that the VSG procedure is "not medically necessary" and thus denied my claim. I am self-pay. I have a BMI of 35.5 + high blood pressure + high cholesterol. My BMI falls into Class 1 Obesity' date=' not morbid obesity. I view the procedure as medically necessary. That's why I am going to pay for the procedure myself. I am disappointed with BCBS' decision. I am not an insurance expert. It seems reasonable to me that your BMI would motivate BCBS to say that you procedure is medically necessary. Apparently, our employers set conditions for the insurers. I want better health and am hoping that VSG surgery will help me lower my blood pressure and lower my "bad" cholesterol. I wish you the greatest success![/quote']

I would have your doctor resubmit the claim (maybe more details). I knw they do a lot of resubmissions on claims. You never know they may approve it.

[Savedbyamazinggrace 66]

I have blue cross BMI of 35 ,high blood pressure, cholesterol and sleep apnea and was approved first time for the lap band, i changed my mind and decided to go for the sleeve....awaiting approval now but i see no problems as the requirements are the same. Check and see if all the proper paperwork was sent in and then ask your doc. to submit it again...

[MsShaunaMarie 82]

I too have BCBS of IL but live in Ohio BMI is 52 right now i believe have high blood pressure. I had no problem getting approved, but I did have to do 6 months with a dietitian and dr and a psych eval, and have them send in their letters to BCBS to get approval.

[MsShaunaMarie 82]

I am also with BCBS of IL. Did you have to do the 6 month deal where you talk with a dietician monthly? I am in my 2nd or 3rd month of it now?

I am scared to death that I will go through this only to be denied. My BMI is 49 though. The office keeps telling me that I will know front the begining if they are going to deny me.

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Hey was just wondering how you were doing with your 6 months if you finished with it yet or not. I know I was worried to while I was doing my 6 months that I would go throught it all and they would still deny me but as long as you show a weight loss when u go in u will be fine.

[LA_dreamer 54]

I have BCBS of NC so I dont know what your insurance requires but have you printed out the actual policy? Mine only accepted certain co-morbidities and they had to have been diagnosed for a certain period of time (like 6months - a year or something ) also my bmi had to be above 35 (with co-morbidities) or 40 (without) for atleast 5 years.

[cbd 78]

Mine is just being submittted to insurance now. I have a bmi of 37 with comorbidities. I am nervous after reading all of these entries that I will be denied. I don't think self pay will be an option. I will be calling the insurance co ordinator next week to touch base and make sure she has everything she needs to submit.

[Ljp 157]

If anyone dont get approved & self pay is an option. My cousin & I both had surgery in Acuna, Mexico with no complications. Hospital is very very clean (constantly had someone sweeping & mopping) & after crossing the border from Del Rio the hospital is like 2 blocks. My Dr. Name is Dr. Luis Alberto Cruz Gandara ( he went by Dr. Crus). 772-0915. Something to think about.