Low BMI BCBSIL

[MrsRP 36]

Hello everyone

I started the process a month ago when I met with the surgeon. I had a psych eval and I'm good for that. My BMI is 35 and I have osteoarthritis (undiagnosed). As far as I know I don't have diabetes and don't have high blood pressure. Did the sleep study and no sleep apnea.

I technically qualify because of the osteoarthritis but I'm very nervous that my insurance won't cover for the surgery.

Anyone here has had 'low BMI' and gotten approved? I have blue cross blue shield of Illinois.

Meeting with my surgeon again to see what the next step will be.

[CrazyCatLadyinLA 17]

The undiagnosed osteoarthritis may cause a problem. I have BCBSIL PPO. I had BMI of 38 and undiagnosed hypercholesterolemia (high cholesterol) that is one of BCBSIL recognized co-morbidity. The surgeon told me to see my PCP about getting medication for it and to see about my blood pressure (also high and undiagnosed). PCP put me on cholesterol med and 2 weeks later surgeon submitted my preauthorization request. BCBSIL sent a denial one week later saying that there was no record of my co-morbidity being unsuccessfully treated by currently accepted medical best practice. No just enough to have the co-morbidity but also need to show no success with medical treatment - which seem to include an actual diagnosis.

Hopefully you have better luck with BCBSIL.

[MrsRP 36]

The undiagnosed osteoarthritis may cause a problem. I have BCBSIL PPO. I had BMI of 38 and undiagnosed hypercholesterolemia (high cholesterol) that is one of BCBSIL recognized co-morbidity. The surgeon told me to see my PCP about getting medication for it and to see about my blood pressure (also high and undiagnosed). PCP put me on cholesterol med and 2 weeks later surgeon submitted my preauthorization request. BCBSIL sent a denial one week later saying that there was no record of my co-morbidity being unsuccessfully treated by currently accepted medical best practice. No just enough to have the co-morbidity but also need to show no success with medical treatment - which seem to include an actual diagnosis.

Hopefully you have better luck with BCBSIL.

Thank you so much! That's my biggest fear. I have an appointment next week and we shall see what they the surgeons team tell me.

I really appreciate your response. More than you know.

The insurance didn't say how long you would have to wait before it's a 'fail of treatment'?

[CrazyCatLadyinLA 17]

No, BCBSIL didn't give any further info about treatment length. Doubt they would either.

However ... My surgeon's office called me today to say that they resubmitted my preauthorization request - and it was APPROVED! If I were a cynical person I would think that the insurance company had purposefully rejected me in December in order to push me out into a new plan year with reset deductibles, etc., especially since the rejection and subsequent approval happened over the span of 3 weeks. ???? I think having an official dx of high cholesterol was key so definitely get your medical conditions formally diagnosed and part of your medical record. Fingers crossed for you!

How is that hospital pre-certification suppose to work? Do you have to call BCBSIL? Or does the surgeon? The hospital? My plan has $300 hospital co-pay as well but I would obviously love to have it waived if possible.

Cheers!

[MrsRP 36]

Omg congrats

I went in for a sonogram and blood work Friday. I'm getting a letter of necessity from my PCP. Hopefully my cholesterol is up too. I remember when I did it last it was border line.

I have a $300 copay too. They rep told me that for pre certification I can call the insurance once I have a date to tell them what code they are using for the sugary, how long my hospital stay will be, how's the surgeon and what hospital. I think that when its my turn (crossing my fingers as the surgeon wants to submit next week) I'll call but I'll also have the doctors office call to pre certify. And a few days before surgery I would call insurance to double check that it's all good.

These days you can't always trust people do their jobs.

Congratulations on your approval. I am so excited for you!!!!!!!!

[MrsRP 36]

Submitting tomorrow. My BMI went up to 37. I have high lol and high cholesterol and my a1c is in the pre diabetic range. And my long history of knee pains.

Hoping to good that's enough for approval. If I do get approved we are looking for March-April surgery as I'm traveling and come back mid March. Can't wait to know what the insurance says!!

[CrazyCatLadyinLA 17]

Fingers crossed! ????

[ColdFred 4]

Hi,

I have BCBS of NC. I hope to have my surgery date set for mid-March. My BMI is 36 but I have other pre-morbidity conditions...Diabetes, NASH, sleep apnea . I qualified for surgery and my

MD wants me to go with the Duo-switch bypass. I thought since I'm starting at 196 lbs. he would

agree with a sleeve. But he likes the switch to get rid of my diabetes and NASH. I think my

other conditions is why I qualified for the surgery. So hopefully your insurance will do the same for you.

Even though my weight isn't as high as other patients, I pray this surgery will increase my lifespan

and rid myself of 2 diseases.

[MrsRP 36]

Update

I received a letter today from the insurance company. Denied. They say the surgeon didn't provide proof of nutritional counseling or behavior modification consults. Which I did both. So they didn't say anything about BMI or comorbidities. Tomorrow I'm stopping by with the letter so they can appeal.

[MrsRP 36]

Hello everyone

I've been MIA for a while. But today finally after 8 weeks of submitting my paperwork to the insurance company and being on the pre-op diet for 4 days: my surgery was approved! I'm scheduled for April 18th! So happy. Finally this is really happening! After going back and forth with my insurance company it's all good! It's like I still can't believe it!

Woohoo.

[ColdFred 4]

Congrats. on getting approval. I got my approval last week and spoke at length

to one of the insurance bariatric specialists. She told be that my BMI was borderline but comorbidities pushed my approval over the edge. I'm scheduled for surgery May 9th. I'm ready to go through it. I do want to

hear from people about the aftermath of surgery. The pluses and minuses.

[MrsRP 36]

Congrats. on getting approval. I got my approval last week and spoke at length

to one of the insurance bariatric specialists. She told be that my BMI was borderline but comorbidities pushed my approval over the edge. I'm scheduled for surgery May 9th. I'm ready to go through it. I do want to

hear from people about the aftermath of surgery. The pluses and minuses.

Thank you. They had no issues with my weight or co morbidities. They kept claiming they never got the letter from the surgeon attesting that I did counseling and nutrition as require by them. Then they had a peer to peer review with the Doctor, that had to be scheduled. After that they sent in the letter and it got sent to the 'wrong' department. When the case manager called on Tuesday they told her the only way they would mark the case as urgent was if I called. Which I did but it took two days and some pressure for them to do it.

I'm just glad that is all done. Happy to have 5 days down on pre-op. Since I started even before it was approved. [emoji16][emoji16]