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

My Insurance Story - Blue Cross Blue Shield Of Illinois



Recommended Posts

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.

Share this post


Link to post
Share on other sites

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

Share this post


Link to post
Share on other sites

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.

Sent from my iPhone using VST

Share this post


Link to post
Share on other sites

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!

Share this post


Link to post
Share on other sites

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. :unsure:

Share this post


Link to post
Share on other sites

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.

Share this post


Link to post
Share on other sites

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.

Share this post


Link to post
Share on other sites

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.

Share this post


Link to post
Share on other sites

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...

Share this post


Link to post
Share on other sites

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.

Share this post


Link to post
Share on other sites

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.

Sent from my iPhone using VST

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. :)

Share this post


Link to post
Share on other sites

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.

Share this post


Link to post
Share on other sites

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.

Share this post


Link to post
Share on other sites

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.

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

    ×