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.

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.

I am so happy to hear that everything is working out! I know you will feel better once you get your approval but it sounds like it is just a matter of time!! You go girl!!!

Good luck!

The insurance is so frustrating. I have Cigna, which covers it, but my employer has it excluded. I was 'lucky' in that a co-worker went through the stress to figure this all out last year, so I got to skip it, but am stuck paying myself. Less emotional stress, just more financial.

I hope this goes through quickly for you. I am having my surgery on dec 9th, maybe we will be around the same time.

I am so glad you got mad enough to fight for yourself. I have no doubt if you keep up that tenacity that you will not only be sleeved but you will do great! Good luck!

Today, Monday November 11, 900am, after 8.5 months of working on getting sleeved , I was approved. There were big mistakes made at BCBS of Illinois which lead to my denials. After nine calls to BCBS, two denials, working closely with the representative from my Bariatric Center, getting a benefit advocate from my companies Human Resources Department, and being very tenacious, it finally came through.

Now, it is going to take a few days for my Dr's Office to get the approval in writing from BCBSIL but the office did call BCBSIL to get the approval. I have to go to the pre-op class and then I am set.

My advise to anyone that is denied VSG Surgery is to make sure that they get a copy of their policy and the exclusions. 8.5 months ago I was approved to begin the program so this denial came out of the blue. My file became more complicated after the denials. Erroneous information had been added to my file that were not part of my policy. Unfortunately the representatives at BCBSIL read the incorrect information and kept telling me the procedure was denied.

Thank you for all of your support everyone. I guess working this hard to get approved really makes me understand the importance of this surgery for me. It gives me, and everyone else that suffers from obesity a chance to have a wonderful, happy, healthy, longer life. Two weeks ago my hope for a healthier future was dashed. Today I am smiling from ear to ear.

Again.......it is a go!

I am so glad you advocated for yourself! Please keep us updated.

November 22, 2013 100pm.............................it is official!!!!!!! I am over the moon.

November 22, 2013 100pm.............................it is official!!!!!!! I am over the moon.

I couldn't be happier for you! ! And you got that November date you were hoping for it's gotta feel good knowing not only did you make this huge decision for yourself but you fought for it and you won! You've barely started your journey and your already and inspiration!

Seela

Hopefully, my two denials will give others the strength to fight their insurance for their surgery as well. If there is an exclusion to your policy, there is nothing you can do. My only suggestion for that is, make sure there is that exclusion. For two weeks I kept hearing, "There is an exclusion in your policy". Finally, I said,"Read it to me, because I have a copy of my policy and I don't see that exclusion". Get a copy of that exclusion. They couldn't read it to me because it wasn't there. The second issue I came across was misinformation in my file. Somewhere, after my initial denial, a biliopancreatic diversion was listed as my surgery. I still haven't received a straight answer on where that came from. My Dr was extremely thorough and documented our two visits with the Vertical Sleeve as my surgery. Both of those visits were covered by insurance.

These last three weeks have been a roller coaster for me. Now, more than ever, I am positive that I am ready to proceed with the sleeve. I am nervous, scarred and a little anxious. After all, I am embarking on an exciting new way of life. If I didn't take it seriously then I wouldn't understand what this procedure is all about. It is no quick fix it is a life changer.

$25,000.00 richer........thank goodness for insurance!

Me

I'm so glad for you! Your tenacity in continuing to fight for what is rightfully insured is inspiring. You only have a week and a half left before surgery! Do you have to do some kind of pre-op diet?

Rena

Anticipating a positive appeal from the insurance I began the pre-op diet two weeks ago. (After a frustrating two days of splurging after the denial) My surgeon does not require fasting, just high protein and vegetables, low calorie. I have been doing 2 Unjury shakes a day and 3oz meat and tons of veggies for dinner. It is tough but I feel pretty good. Nothing was going to get in the way of this surgery!!

Are you sleeved yet or awaiting your big day?

I'm so happy to hear that everything worked out for you!

My surgeon forwarded my paperwork to BCBS of Alabama on Nov. 11th. Supposedly they have 30 days to reply, so I'm not going to get my hopes up for a sleeve date by the end of the year. I'll just keep plugging along.

My surgeon's office says they are booked up anyway through Christmas. Bummer. I have a lot of vacation time that I need to take between now and then, and it would have been the perfect time for me to get sleeved.

Rena

Actually, BCBS was really quick on the reply......it was just a denial!!! They are normally pretty efficient. Are you sure the Dr. can't fit you in anytime before the 1st of the year? Psychologically it would be such a relief.

Sassy

November 22, 2013 100pm.............................it is official!!!!!!! I am over the moon.

SassyTink

WooHoo, Woo Hoo!!!!!!

party dance, party dance

being so pro-active, persistant - way to go!!!!!

next friday WLS???

holy moly

those feelings your dealing with - nerves, excitement

totally normal

those feelings will increase over these next few days

you made the wise decision to have this life changing surgery!!!!

don't 2nd guess yourself now, of after the fact

if you continue to work as hard as you did before surgery, as you will now -

wow, what a success you will be!!!!

by the way, damnnnn those insurance companies

good luck

speedy recovery

kathy

what a success you will be/are

i have confidence, i know you will do great

Thanks ProudGrammy! Right now all I want is to bit into a cheeseburger. This pre-op is so hard but I do have tons of energy. I guess a pure protein diet is what the body wants! 5 days to go......YIKES!