Ok, I have been going through this for a little better than a year now and am sick to death of playing BC/BS of IL. games. I was denied the first time because they said my doctor wasn't specific enough in her notes about my 6 month diet and she didn't put her signature on a required 5 year history form - It had the letter head and was included in the packet of information, but it wasn't signed.

I went through another 6 months of dieting and my doctor writing a book every time I seen her and she signed the 5 year form only to submit everything (once again) on June 2nd and be told on June 18th that it's still sitting at BC/BS and "they" are not sure why it hasn't been forwarded to the review board. I called today to check to see where the file was at - A very nice and perky rep. says, "Wow, you've been doing this for over a year now." - I gritted my teeth and nicely said, "Yes I have, please check on things and let me know where my file is and if someone has deemed this procedure medically necessary, thanks." She put me on hold forever.... (I admit I took this as a positive sign) only to tell me, "Yes someone has it but they're on vacation until the end of the week." AHHHHH..... I am so frustrated!

Thanks for letting me vent once again.

My plan is PPO.

I submitted 6 consecutive months / 6 individual doctor evaluations stating all my vitals; height, weight and blood pressures, my BMI, my exercise routine for the month, my food intake/calories for the month and what she thinks I should/shouldn't do the following month.

I also submitted all the other pre-req.'s 5 year history, did all the tests the surgeon ordered, psych. eval., physician letter, orthopedic surgeon's letter (bad knees), etc...

The first denial said my doctor didn't make enough notes at my 6 month evaluation and she had failed to sign the five year history - even though it was on letter head.

Second denial said I lacked a six month clinically supervised diet......

It's frustrating because BC/BS lets a board make the "Medically Necessary" decisions but they cannot give you a name, number or extension to this MRU board in order to get a clear answer on why they denied it or what you have to do to get approved. The terms and policies are so general a lot is left up to interpretation and that is where they get you!

Mist,

What are you doing now after the second denial?? I feel soo frustrated. I wonder how anyone ever gets approved with this insurance!

I made an appointment with my doctor to discuss what she thinks we can do/start another 6 month diet. I'm also considering going to a local lawyer and getting a letter wrote with a whole lot of legal mumbo -jumbo demanding I get a better explanation of denial or an approval???

We'll see....

According to my policy l don't even need an approval, yet l was NOT approved...and you're right, its some board who just decides...My daughter happens to work in a major medical com[pany approving all types of surgery and disabilities...She is 21 years old, and has the ability to affect someones life..NO MEDICAL training...we are at the mercy of our insurance carriers

After I get everything I "think they should need" and resubmit, if I am denied I will appeal with the help of Obesity Law. This is crazy.

I also have bcbs il HMO. they insist (BCBS) that I have NO prereq's to be approved besides having a referral from my pcp deeming it med nec. BUT my med group is strict and has a 6m diet (used to be 12m w/10% wt loss) the nurse from the med grp says I don't even have to meet w/a doc, just weigh in every month. This is so weird. I am on month 2 and will not give up. If I were you I would get a lawyer today and start ruffeling their feathers. I bet you'll get your approval w/in 24 hours.

According to my policy l don't even need an approval, yet l was NOT approved...and you're right, its some board who just decides...My daughter happens to work in a major medical com[pany approving all types of surgery and disabilities...She is 21 years old, and has the ability to affect someones life..NO MEDICAL training...we are at the mercy of our insurance carriers

You have BCBS Federal if I remember correctly. Do you mind sharing why you were not approved? Also, which one do you have? Basic or Standard. I am going through this process with the same insurance and I read the same thing you did. I am concerned I will be denied too when it's submitted.

Thanks :thumbup:

My husband and I have just started the journey. Now i am nervous and wondering if it is even worth fighting the insurance company. We have BCBS of Illinois PPO. Some people have told us they didnt need the 6 months of diet, some say they did and everything was fine. Does it matter how much u weigh? My husband has diabities really bad, sleep apnea, and weighs almost 500lbs. We have been going to a Dr. Gupta. We went for a year, and just now started back for 6 months and have been told that his documentation might not be good enough. What are they looking for? Would love to hear from anyone who lives near Rockford, or Dekalb area. We are going threw Mercy Bariatric Center in Harvard.

The problem that most of us are having is that they are stating that the 6 mo diet notes are not in depth enough. The bigger problem is that they are very vague with the denial and the denial letter. It seems to me your hubby should have no problem with getting approved but you just never know. I thought I did everything by the book, as I printed out a copy of bc medical policy on morbid obesity surgery. I took this form to every dr I saw to make sure the notes had what was on the paper. Still DENIED. I am trying again in a few weeks. I will be getting the notes together myself and sending them in. I used to be a surgery scheduler and did appeals all the time, so I will include a nice long letter too. I am goona try until I have exhausted everything I know to do, and like I said before I will be contacting a lawyer or Obesity Law. It is just the principle of the matter now!!! Good luck!!

tamihott, you know what they are doing is illigal. they are stalling you. it sounds like you have gone beyond what the average person has to do to be approved. they are being unreasonable. there is no such thing as not enough doctors notes about a diet. that is silly. :thumbup:i hope you are journaling all this and then get a lawyer. you will definately get your surgery and maybe win a lawsuit :tt2: i will give them h#$% if they do this to me at the end of my 6m. im already worried.

why did my med grp say that I don't even need to see a doc during this diet. the rn said she hasn't heard of any denials.

just one more thing for me to fret over

by the way, i am an RN and I have never had a patient say they regret having WLS. if anything they say they wish they had done it sooner.

good luck and please keep us posted.

Where can i go online to see what bcbs is looking for as far as the 6 month diets is concerened. i know they have a website, but not sure where to look. thanks for all the help

Thanks for the support guys! I really need to keep the momentum up and not get discouraged. The website is bcbsil.com when you get to the main page click on providers at the top of the page, then on the side you will see many options. Closer to the bottom it says medical policies, click it. A disclaimer will pop up and you need to scroll to the bottom and click I agree. On the next page will be a place to type what you are looking for. It is on the left hand side. Type in morbid obesity. There is only one option. This policy goes over any WLS surgery that is covered and what they want and require for approval. If you have any trouble let me know. Tamara

I found out yesterday that I was approved. I had to go through Obesity Law, but I got approved. So many people meet all the requirements, but BCBS IL continues to deny them. Is there some way of reporting them. They do not honor their own policy.

l did the same thing with Blue Cross Federal....l wrote obesity law.com and l was instantly approved....

How much did it cost you? How long did it take? I heard Obesitylaw.com is slow to get back with you, are they?

Thanks for answering my questions.