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.

I have an exclusion on my policy as well and the first time they told me it wasnt allowed so i called again and the person said no i can get the surgery as long is i do that long list of things. So i make an appt at GBMC and they call me and tell me my insurance DOES NOT cover the surgery of an kind for any reason, due to my employers insurance broker choosing to exclude it to save money. I was devastated but now i am scheduled for self pay in Mexico w Dr. Illan on jan 17 2014.

Good luck to you!

I have an exclusion on my policy as well and the first time they told me it wasnt allowed so i called again and the person said no i can get the surgery as long is i do that long list of things. So i make an appt at GBMC and they call me and tell me my insurance DOES NOT cover the surgery of an kind for any reason, due to my employers insurance broker choosing to exclude it to save money. I was devastated but now i am scheduled for self pay in Mexico w Dr. Illan on jan 17 2014. Good luck to you!

Congrats! I had the same problem with my insurance, My surgery is scheduled for 2/17/14 with dr Ortiz in Mexico

I also have BCBS and my policy states those same requirements. Don't give up...get mad. Take charge of your own health plans and make sure the doctor's office gets all of those requirement met. Your physician has many more patients with that same insurance so they must know what information they are needing. Pull yourself together and don't take no for an answer. Call the Drs office every day. If they don't call you back, write them a letter. Make yourself heard. If everything fails, get your money back from them and go to Mexico for your surgery. If you want it badly enough, you will find the way.

I did my research in 3 days about this whole issue and decided to go to Angeles hospital in Tijuana

It took us less then a week from deciding to do the gastric sleeve to getting it DONE here

I'm writing this while sitting in a private suite in Angeles hospital Tijuana

My daughter had the surgery today she is sleeping now

Reading your story makes me sad but there is a better way for 7500 dolors and you will find out how corrupt and dysfunctional OUR health care system is

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

It took them a week and a half, but I was denied. Evidently I haven't been fat enough long enough, and my co-morbidities aren't severe enough for the past 3 years. Also my primary doc didn't document the 6 month requirement along with the registered dietitian, and they didn't like that. I'm going to appeal, of course, but it looks like it won't be this year. My surgeon's office even gave me a tentative date of Dec. 17th.