Right now I am so devastated I can barely type. My process began on March 20 2013, when I notified BCBS of Illinois concerning Bariatric Surgery. Below is a copy of the correspondence:

03/20/2013 18:44:00 -- Member Question:

Hello

Unfortunately, at this time I am looking into Bariatric Surgery at the recommendation of my internist. We have a Blue Distinction Bariatric Center in Portland. What are the different steps that Blue Cross requires, under my plan for this surgery.

Response:

Bariatric Surgery

03/21/2013 15:12:31 - HCSC Response:

Hi Patrice,

Surgical treatment of morbid obesity may be considered eligible for coverage when all of the physical, clinical and psychological indications are documented according to Blue Cross Blue Shield of Illinois current medical policy. A letter of support and/or explanation is helpful but alone will not be considered sufficient documentation to make a medical necessity determination.

We are not in a position to consider the request for surgical treatment of morbid obesity due to the lack of available medical documentation to determine medical necessity based on Blue Cross Blue Shield of Illinois medical policy. The following documented clinical information is necessary for further review.

For a member to be considered eligible for benefit coverage of bariatric surgery to treat morbid obesity, the member must meet the following two criteria:

1. Diagnosis of morbid obesity, defined as a:

- Body mass index (BMI) equal to or greater than 40 kg/meter (* see guidelines below for BMI calculation); OR

- BMI equal to or greater than 35kg/meters with at least two (2) of the following comorbid conditions related to obesity that have not responded to maximum medical management and that are generally expected to be reversed or improved by bariatric treatment:

o Hypertension, OR

o Dyslipidemia, OR

o Diabetes mellitus, OR

o Coronary heart disease, OR

o sleep apnea, OR

o Osteoarthritis; AND

2. Documentation from the requesting surgical program that:

- Growth is completed (generally, growth is considered completed by 18 years of age); AND

- Documentation from the surgeon attesting that the patient has been educated in and understands the post-operative regimen, which should include ALL of the following components:

1. Nutrition program, which may include a very low calorie diet or a recognized commercial diet-based weight loss program; AND

2. Behavior modification or behavioral health interventions; AND

3. Counseling and instruction on exercise and increased physical activity; AND

4. Ongoing support for lifestyle changes to make and maintain appropriate choices that will reduce health risk factors and improve overall health; AND

- Patient has completed an evaluation by a licensed professional counselor, psychologist or psychiatrist within the 12 months preceding the request for surgery. This evaluation should document:

1. The absence of significant psychopathology that would hinder the ability of an individual to understand the procedure and comply with medical/surgical recommendations, AND

2. The absence of any psychological comorbidity that could contribute to weight mismanagement or a diagnosed eating disorder, AND

3. The patient's willingness to comply with preoperative and postoperative treatment plans.

The member and their physician(s) are urged to review the full text of the Blue Cross Blue Shield Illinois (BCBSIL) medical policy on this subject on the BCBSIL Website at www.bcbsil.com. Choose the "provider" link at the top of the Website and select medical policies: Surgery for Morbid Obesity (search by policy title).

If you any further questions or concerns, please contact our customer service department at the toll-free number on the back of your Blue Cross Blue Shield identification card or via the Message Center on Blue Access for Members.

Sincerely,

Cheryl M.

Blue Cross Blue Shield Illinois

Customer Service Center

For the last six months I have seen the Bariatric Centers Dr's, nutritionist, physical therapist, psychologist and 80% of every appointment was covered by my policy. I have pain my 1500.00 out of pocket expenses and ready to go. Today I found out that my insurance policy has an exemption on Bariatric Surgery.

WHAT?????? The insurance company gave me the info above and paid all of the pre surgery visits.

I assumed the Dr's office did their job,

• Submit an electronic Eligibility & Benefits Inquiry (ANSI 270 transaction) to BCBSIL through your preferred online vendor portal.
  

Now I am left disappointed and totally depressed. I just can't understand how this happens.

take a deep breath and remember that you do have a medical necessity with your hip. what is your BMI? Do you have any medical issues such as diabetes and/or sleep apnea, high blood pressure? Talk to your PCP and see how he/she could help you.....

Thank you for the words of encouragement girls. I have just begun the fight. I will find out why the Bariatric Center did not check with my insurance 6 months ago. They took all of my insurance information before I even got my first appointment. What did the insurance say at that time? Why did BCBS pay for all of the appointments if my policy has an exclusion? Why did BCBS send me a list of what I have to do?

I will seek reimbursement of the $1500.00 out of pocket expense (Deductible), or I will request a discount to make this surgery happen. They need to make this affordable or me. If this office does not rectify this situation I will get a Personal Injury Attorney involved. This entire 6 months has been a scam if they don't fix the situation. They do not know who they are dealing with. I am not a passive, poor me, kind of gal. I am assertive and have tried my tears and am ready to fight. The problem I am having is being let down by people I trusted.

Thank you for the words of encouragement girls. I have just begun the fight. I will find out why the Bariatric Center did not check with my insurance 6 months ago. They took all of my insurance information before I even got my first appointment. What did the insurance say at that time? Why did BCBS pay for all of the appointments if my policy has an exclusion? Why did BCBS send me a list of what I have to do?

I will seek reimbursement of the $1500.00 out of pocket expense (Deductible), or I will request a discount to make this surgery happen. They need to make this affordable or me. If this office does not rectify this situation I will get a Personal Injury Attorney involved. This entire 6 months has been a scam if they don't fix the situation. They do not know who they are dealing with. I am not a passive, poor me, kind of gal. I am assertive and have tried my tears and am ready to fight. The problem I am having is being let down by people I trusted.

Way to go!! Once those tears are dried the resolve sets in and I think you will get some results!!

I'm proud of you. And when it's all over you'll be so much more proud of yourself for not giving up. Please keep us posted and I will visualize you sip, sip, sipping away.

My heart hurts for you!!! I would be devastated too. I'm glad you've dried the tears and are ready to fight!! Please keep us posted!!!!

So i'm wondering if your doctors office didn't follow through and do the initial paperwork and see if your insurance covers it? When I went to the bariatric Center at my local hospital the first thing I asked was how do I know if this is covered? I called my insurance company and they said the same thing there is an exclusion it will never be covered under my policy. The initial tests and labs could be covered but the actual surgery wouldn't be covered. That really had me upset for a while until I started researching my options as a self-pay are in Mexico. It was the only choice I had because there's no way I can afford surgery at my local hospital it'll take me years to save up that money. I feel your pain and I'm so sorry that you had to go through all of this. I wish you the best.

take a deep breath and remember that you do have a medical necessity with your hip. what is your BMI? Do you have any medical issues such as diabetes and/or sleep apnea' date=' high blood pressure? Talk to your PCP and see how he/she could help you.....[/quote']

The problem is if there is an exclusion policy to her policy, it will never be covered

Or what issues she has that could make it medically necessary. It sounds like that is what she's dealing with…

Guess what? I was on the phone at 0800 to the Bariatric Center. The insurance coordinator was in and told me that she got an okay from BCBS on March 21 2013. The gastric sleeve procedure was covered under my plan if all of the pre-surgical requirements were accomplished. She couldn't believe that I was denied because of an exclusion in my policy. This was news to my Dr's office. She promised she would call BCBS and find out what is going on.

2 hours later I couldn't wait any longer and called BCBS once again. I got a really knowledgeable woman on the phone that had quite a bit of empathy for me. What I did tell her was I looked up my policy on my company website and it explains bariatric surgery as part of my plan. I wanted an answer to what my policy excluded as far as bariatric surgery. She put me on hold for at least 10 minutes. When she returned to the call she said, "THERE IS NOT AN EXCLUSION ON YOUR POLICY REGARDING BARIATRIC SURGERY, IT WAS AN ERROR THAT THE DENIAL LETTER WENT OUT TO YOU." She said, she could not tell me that my surgery was approved but there is not an exclusion. She told me that she would give my file to her manager to be expedited through the system because of the error.

Now, let's see how fast everybody steps up to the plate to help me get that November date. I am so relieved. Thank you everyone for all of your support and kind words.

ME

I have BcBs as well when I went to the first seminar I gave my bariatric center all my insurance info .... They found out I also had the exclusion clause ..... So I am a self pay ... It really sounds like the insurance co screwed up sometimes you can appeal the exclusion if its a medical necessity with dr assistance .... So sorry and best of luck

Tbird49

I do not have the exclusion to my policy, somebody at BCBS was not being very thorough. I will be approved, there was never a reason to be denied and that is why I was in such shock. I am still weary until I get the APPROVED and date from my Dr.

Sleeved 8/21 i have bcbs and they paid.. You Dr secretaries should know how to get this approved.

I had my husband's insurance. It was BCBS of IL and his company had all weight loss surgery excluded. I am able to have mine now because I am under Medicare. We paid a high premium for BCBS and always thought we had the best coverage. Never though surgery for obesity would be denied

The problem is if there is an exclusion policy to her policy, it will never be covered Or what issues she has that could make it medically necessary. It sounds like that is what she's dealing with…

i agree but I didn't read anything about an exclusion I wonder if I missed it.

The misinformation continues! I have been on a roller coaster all week. I called BCBS of Illinois Monday and was told my surgery request was denied, once again. The reason, an exclusion in my policy. I went on line, found my policy on my company website, scrutinized that policy, came to the conclusion that BCBS is mistaken.

Next, I call my companies benefits department and opened a "Ticket" with an employee advocate. She read the policy as well as the exclusions and told me bariatric surgery prior to 2010 was not covered. It is covered now with the inclusion of using a Blue Distinction Hospital. That could be the issue. The person at BCBS might not be reading the entire policy.

With this new information I called BCBS on Wednesday. I got a really terrific woman named Donna. After putting me on hold for 10 minutes Donna told me that the surgery I wanted should not be denied. It seems there was a problem with reading my entire policy. It says, "Bariatric Surgery will not not be covered" next line, "Unless the Provider is a Blue Distinction Hospital of Excellence" I guess the person determining my surgery request couldn't bother reading the next line of the policy!!! Donna told me she would reopen my request and give it 48hrs.

Now it is Friday. I called BCBS, another denial. They had a biliopancreatic diversion switch as my procedure and not the vertical sleeve. Some idiot at BCBS had assumed that was the procedure without looking at my Dr's notes and the entire packet sent to them. Mistake number 2. Ashley at BCBS was dumbstruck at the 50 pages of notes in my file at BCBS. She apologized and told me about this procedure and that is not covered in my policy. I told her my physicians office doesn't even do the procedure. This procedure was never discussed and I need someone to pay attention at BCBS. I told her I had a benefits advocate from my company on it and I wanted the rectified! She promised me she would walk my file through the powers that be and call me back. At 250pm, Friday, she was going home at 500pm Central Time, she called me to tell me my file was reopened, the benefit was hi lighted in my policy, and the correct procedure was added to my surgery request. Her final words were, "There is no reason for a denial, I am so sorry."

It takes 48 hours for a re-opened file to get an approval. I will be on the phone Monday morning! I called my Dr's Office and they are flabbergasted. They have done everything right, it is not their fault. They have assured me they will get me in for surgery as fast as they can after the approval.

Wow, I can't believe I working this hard to cut 2/3's of my tummy off!

More drama to come............

P.S. I have crossed my "T's" and dotted my "I's" as far as following the guideline BCBS sent me initially. I also have, osteoarthritis of my right hip, severe sleep apnea and am pre-diabetic. The co-morbidities are there. We shall see what new reason appears to deny me.