I was just contacted by my surgreons office on Friday, regarding the requirements for Lapband surgery. I was prepared for lots of work ie..psych appt 6 month dr weight loss even a nutrionist and 5 year history of morbid obesity, but she seemed discouraged already. She told me that if you go below the 40 BMI during that 5 year period you are automatically excluded. I was shocked and got onto the bcbsil website and read the medical policies on the srugery. It did not say that you could not drop below 40 BMI. I read it as they just wanted to make sure you had weight issues for years not just a short period of time. She continued to state in 2 1/2 years she had gotten only one approval from this particular insurance co. I was getting discouraged, then later in the conversation she proceeded to tell me that honestly when most people find out about all the guidelines and the 6 mo diet they choose to go the self pay route. I think if it is worth doing you have to put some work into it, and that is what my insurance is for! I pay good money for it and think it is worth a shot to get all my stuff together and submit it. I was really just wondering if there were any experiences with this insurance and what was the outcome. Thanks for any advice you have. Tamara

I'm insured through my husband's employer GADCO. It has nothing to do with employer but everything to do with your policy negotiations and what is finally set up - Some companies exclude certain things/surgeries to save money.

Yep. That's what I thought. I know my doctors office called the provider number on my card, which takes them to the actual AT&T department at BCBS... who told them bariatric services are covered. Hard to beleive when they won't even pay for this much less expensive sleep study without enough red tape to choke you.

Just got a call from the woman at the hospital where I am having my sleep study done... the insurance co told her I don't need a preauthorization...but that it is strongly recommeded, and of course...if I am found positive it will be paid for. Evidently, the problem is they consider this COSMETIC!!!! :thumbup:

I don't care that I am requestng what they consider cosmetic surgery (sure....lap band could be considered cosmetic, I guess), I don't see a sleep study as being in any way cosmetic...this is a potentially life saving test....Lord save me from idiots (and insurance companies)

I think BCBS IL gives zero training to the people they hire, and they hire people with zero experience. The only training they receive is to say "It's not covered", and to deny everything.

I think BCBS IL gives zero training to the people they hire, and they hire people with zero experience. The only training they receive is to say "It's not covered", and to deny everything.

You are right there ;(

I agree to that! Had that very experience!!!!!!! Becky

My coworker submitted to BCBSIL about three weeks ago and got her approval a week ago. (we found out halfway through our pre-surgical dieting period that we were both trying to lapband approval, and were going to the same surgeon's office and the same nutritionist. small world) She had only her six month dieting history, psych eval, and five years of weight records (no co-morbidites).

My package (which contained the same, pretty much) was sent off yesterday. I'm supposed to hear something within 15 days.

Both the billing office at my surgeon's and the nutritionist said that they are seeing more and faster BCBSIL approvals recently. Speculation is that first-time denials and then having to go through the appeal process was costing them too much.

Just sitting here keeping my fingers crossed that I have the same kind of fast turnaround that my coworker did!

- jen

Wow!! There really may be hope for us all. Thanks for the positive post about BC/BS of illinois. I am sure we were all in need of that boost! Tamara

I guess that's not accross the board because I talked to the insurance person at my surgeon's office today to see if Obesity Law had accepted my case, and she said that they are amazed that that all of a sudden their BCBS TX and IL claims are being denied when they can't figure out why. She said that they have had a sudden increase in denials for authorizations that appear to meet criteria per BCBS policy. Oh, well. Maybe that means I will get approved on appeal.

The day before yesterday I talked to my surgeon a couple of times, by phone. One time for almost an hour!!!

He basically told me thatn if BCBS demands a diet, they are not going to waive that.

I pretty well knew that...it's just that I was all ramped up to go through with this...also I HAVE to have hernia surgery..soon! I just don't see why they won't authorize the lapband to be done the same time as the "medically necessary" hernia repair. BTW, this is my 2nd hernia in less than 4 years (3rd lifetime in the midsection...I know I have one or two more in the pannis (the hanging down belly area) hoping once I lose the weight I can get those repaired...and possible a tummy tuck. Anyway, the reason I keep tearing and herniating is because of the weight I am carrying in the belly. So.....they can keep paying for hernia repairs, they can have me jump thorugh their hoops, and ultimatley (hopefully) pay for a second full surgery in 6-7 months... or they can...dare I say it?? pay for the surgery now. Makes sense to me. Too bad I don't work for BCBS IL, huh?? I could save them some money. Nope...it's not going to happen :frown:

The doctor called the medical center, and told me he could do the lapband at the same time. It's going to cost me about $5.500 out of pocket. My husband was not thrilled about this, he wants me to jump through their hoops. I was sooo upset. I just want to pay it and move on. Not to mention...I really don't want to have to go through 2 surgeries. He had the attitude that "if you pay for it, the insurance co won..you are doing exactlly what they want you to do" WTH??? It is an insurance co..not a person..this is my life we are talking about here.

He told me "can't you just do Weight Watchers for 6 months" acording to what the docotr infered from the rejection letter..there is more than just going to Weight Watchers needed...you need to be in a "medically supervised program" And, they seem to be quite expensive.

I was so upset, I couldn't stop crying.

Last night we talked about it, and he told me to go ahead and schedule the surgery (we are going out of state for about a month) when I get back, and just charge what needs to be charged. His biggest concern is that if BCBS sees I had a lapband done at the same time, they may reject the hernia surgery (knowing BCBS of Hell, er..I mean IL) that could actually happen. Guess I will have to ask the doctor how is going to bill it, and if he will consider it 2 seperate procedures. So...hopefully I am on my (self payed) way!!!

If the hernia is really bothering you and it needs to be done now, I would probably go ahead and do the Lapband at the same time too. I would just get my ducks in a row about the billing and go for it. If the hernia is not that bothersome, then your hubby is right. Jump through the hoops. Bc does expect most of us to just go self pay. We have to show them that we pay good money for our insurance and we intend to use it. Good luck Tamara

If the hernia is really bothering you and it needs to be done now, I would probably go ahead and do the Lapband at the same time too. I would just get my ducks in a row about the billing and go for it. If the hernia is not that bothersome, then your hubby is right. Jump through the hoops. Bc does expect most of us to just go self pay. We have to show them that we pay good money for our insurance and we intend to use it. Good luck Tamara

I've had the hernia for about 6 months already..part of me says "Hey, what's another 6 months?" But it is starting to hurt a bit more. The surgeon told me to be somewhat careful...that if it starts to strangulate and I go to the ER they are going to do a full open surgery to repair it. I had the last 2 repaired openly...not a lot of fun. <sigh> I just don't know what to do...

My coworker submitted to BCBSIL about three weeks ago and got her approval a week ago. (we found out halfway through our pre-surgical dieting period that we were both trying to lapband approval, and were going to the same surgeon's office and the same nutritionist. small world) She had only her six month dieting history, psych eval, and five years of weight records (no co-morbidites).

My package (which contained the same, pretty much) was sent off yesterday. I'm supposed to hear something within 15 days.

Both the billing office at my surgeon's and the nutritionist said that they are seeing more and faster BCBSIL approvals recently. Speculation is that first-time denials and then having to go through the appeal process was costing them too much.

Just sitting here keeping my fingers crossed that I have the same kind of fast turnaround that my coworker did!

- jen

Quoting myself as an update... I got my approval today, two weeks from submitting initial paperwork, even though she had to refax my weight history because they couldn't read some of it.

*bounce*

- jen

I am still waiting for the preauthorization request to be sent in (again) My surgeons office is waiting for a letter from both my doctors (my old one in MI, and my new one in CO) I fully expect a denial. :thumbup: After all...it is BC/BS of IL , and because I do not have the 6 month diet history. I am just going to bite the bullet and pay the cash ($5500.00) and have the surgery done at the same time as the hernia surgery (which is getting worse every day...it is past time for the surgery)

I am scheduled for June 26th at 1PM. Wow....3 weeks from tomorrow. I am soooo geeked. :thumbup:

Congratulations on your surgery date!!

Congratulations on the date!! I finished my 6 month diet today and paperwork will be sent in next week. Now the hard part starts. Keep your fingers crossed guys. I will keep you posted. Good luck to everyone else with this insurance!!! Tamara