CandaceCares

I have Blue Cross Blue Shield of illinois and the process for approval has been a nightmare.  I read about "dustbuster-00" and her similar problem in getting insurance coverage by the provider above in her recent posts dated April 23, 2011 and it prompted me to join this website.  I had a program that was through a medical group and it was comprehensive and I was on it was 8 months consecutive.  The first information that the bariatric surgeon office sent (received by BCBS or illinois on 2-01-2011) was for the  psychological evaluation (I was considered a "top" candidate for this surgery per the bariatric psychologist).  Included in the packet was ALL the information about the HMR program through the medical group.  The medical groups doctors brought this comprehensive programinin who are internists (it covers all areas with the exception of psychologist).  This HMR program is nationally and medically recognized and the medical group has even made it more comprehensive (even doctors and nurses have been on this program that is how good it is).  This medically supervised diet was much more involved then commerical weight loss programs (NOT saying anythig bad about them).  We see our internist weekly, get blood drawn as required, saw registered dietician/nutritionalist weekly, weighed in weekly and got our HM shakes and foods weekly.  We attended a two hour registered dietician/nurtritionalist class weekly, and did comprehensive log journals (physical activity how much, foods we had consumed for the week, and other calculations showing progress before and after weekly), We would also see nurses who were very involved weekly (so it was comprehensive) and met more then what Blue Cross Blue Shield of illinois would need after reading other posts. So my paperwork was submitted by the bariatric surgeons office (the co-morbidities accidentally got left out from the information due to our error) and it was received on 2-1-2011. So the insurance company had it for 2 weeks to look at the psychological eval and the HMR supervised diet (everything was in the packet). We receive a denial letter dated 2-15-2011 for no information on co-morbidities. IMPORTANT POINT TO REMEMBER: We never received any denials on those two items that were received for review, so after close to four months with one letter (this after we received the first denial on co-morbidities that was not in the packet) the insurance companies SILENCE on the matter would lead any reasonable person to believe those items had already been accepted or we would have received a need for more information denial letter like "dustbuster-00" said she received.  My husband (helping me out)  provided them with co-morbidities information received on 3-29-2011 and BCBS of illinois said it satisfied that requirement. Then all of a sudden out of the clear on April 25, 2011 after BCBS having my paperwork for HMR doctor supervised diet and the psychologist high recommendation report I get a denial letter for not having enough evidence for the HMR program (the EXACT same thing that happened to "dustbuster-00" but this is from 2-1-2011 when the insurance company received the package until 4-25-2011 close to three months later).  The insurance company cannot say the original package was not scanned in, and they can't say they never looked at the package because my husband called in to see that they received it that was sent through the bariactric surgeons office (and they said they did). They could not say they never looked at it since that is all they had and how could they deny me the first time for not having co-morbidities (that were eventually received and approved) without going into the packet and reading it? They have a job to make sure they read and review everything and the first thing they would do BEFORE even looking at anything else (to save their company time and money) is to see if I met or exceeded the 6 month criteria and see what dates they were for and if there was ANYTHING that was not there or was not acceptable that could send a denial letter (just like the co-morbidities, that were not in the packet as first) but that did not happen).   SO THIS IS WHEN THE GAMES BEGIN WITH BCBS OF iLLINOIS AND PLEASE EVERYONE WHO HAS DEALT WITH THE ILLINOIS BCBS LIKE DUSTBUSTER-00 DID (I HOPE SHE WILL RESPOND ALSO) PLEASE LEAVE MESSAGES FOR ME BECAUSE I AM HEARTBROKEN WHAT HAS HAPPENED NEXT AS WILL BE EXPLAINED FURTHER BELOW!  My husband calls BCBS and says why are we getting a denial letter close to three months later on the HMR diet program and the first rep tells him EXACTLY what he needs (because he asked her EXACTLY what do you need so he did NOT have to go through what eventually happened next.  So my husband follows what he is told EXACTLY by a BCBS rep (why wouldn't he) and goes ahead and submits what was asked (AND GUESS WHAT)  we get a second denial on the HMR diet program (same vague STANDARD FORM not enough information as "dustbuster-00" got the run around for also).  So he calls and asked what happened because he supplied them with exactly what the rep asked for that they said would satisfy the approval(and like everyone gets new people each time).  Well you can guess by now what I am going to say next the exact SAME scenario repeats itself above TWO MORE TIMES with 2 more different reps so at the end we get a total of four denial letters (talking to several reps) just on the HMR supervisesd diet alone and that is even with a Manager from our medical group calling them.  On May 25,2011 my husband calls and is transferred to an evaluator (from a rep) and was told they approved the diet program and it's components but almost sent out yet another denial letter (my husband caught their error in time) and told the evaluator to  look at the packet you got back on 2-01-2011 and you will see that the psychological component was met already. that was supposedly missing in the HMR program.  The lady evaluator had to agree and then tried to find something else to deny us on concerning the HMR program which I will explain towards the end.  What had happened is that the HMR did NOT have a psychologist involved in the program (that is what they were going to deny me on) but the psychologist evaluation had been in the packet BCBS had and saw on 2-01-2011.   It was my husband that had to remind the evaluator and make her look this up and this was not a rep (who many times have different stories from each other) but one of the evaluators as mentioned before.  When it came to the reps each time my husband asked EXACTLY what is it you need and we even got the head of the medically supervised diet program manager to contact them and we got a fourth denial letter (just on the diet portion alone) they would tell him (each one something more was needed) yet each time from the first denial letter to the last each rep said this would satisfy the diet portion.  This went on from approximately 4/25/2011 until close to the end of May 2011.  REMEMBER my husband took notes, asked to be recorded, got name, dates, times to protect me since it has caused a great deal of hurt going through this just to get denied again.  SO IT GETS EVEN BETTER.  Since my husband is talking to an evaluator (as identified and names, dates, notes, and asked to be recorded) once he had her look up the psychologist report that was ALL along with the medically nationally recognized and comprehensive weight loss program she said that it satisfied that component (and they had told the weight loss manager who called on her time to let them know how comprehensive it is and they could have told her also that it met the criteria that I had on file for the pyschology portion.  If my husband had not talked to her and called before that letter went out then what!!!!!!  So now the evaluator (same phone call) tells my husband well you have to have your surgery scheduled in BEFORE the end of April 2011 to qualify under the 24 month rule.  He tells her we do and she tells him they will wait for the information.  He calls immediately the coordinator for the bariatric surgeons office and she faxs BCBS of illinois that I was scheduled in prior to that cut off date and also includes a letter going into great detail of my status.  My husband called the next day May 26, 2011 and checks to make sure it was received and he was told it was (once again each time he gets names, dates, asked to be recorded, and he takes notes, so from now on you can assume this when you read what eventually happened to me),  He is told by the rep that the latest data is being reviewed now (he was told that this will meet approval by the evaluator once showing this last piece of information) since everything else AT LEAST WE WERE LED TO BELIEVE was in place for approval.  So since it is Memorial weekend and they are closed on Monday he calls Tuesday 5-31-2011 and is told by a rep that they are still evaluating the paperwork submitted on 5-25-2011.  He does not call the next day and then he calls on 6-02-2011 and he is passed on from a rep to a evaluator and she starts really giving him the run around because he is told we have been denied once again (when we knew the last item met the criteria).  She starts to rehash from the start and he is a very nice man (but had to assert himself not to waste time) and said that all the issues that were suppose to be had been approved.  The co-morbidities had been approved on 3-29-2011 (she agreed), the HMR diet program was approves (she agreed), the psychological component had been met (she agreed), the scheduled in surgery prior to cut off was approved (she had to agree also), the six month consecutive was approved (she had to agree also).  She was told that the only legitimate denial letter was for the co-morbidities that was sent in and got approved way back on 3-29-2011.  That they had the medically supervised very comprehensive (more then most have to provide) had been in their file scanned in and readily on their computer since 2-01-2011 along with a separate but available pyschological evaluation that met any behavior component and I was considered a top candidate for this procedure. That if there had been ANY issue with the diet program then they had an obligation to send this out to us when they sent out (something that was NOT in the packet) the co-morbidity denial letter on 2-15-2011 but this never happened.  REMEMBER we now have one denial letter for co-morbidities dated 2-15-2011, four denials for the diet program (they messed up on not us), and almost one more (but my husband caught in time since the right hand does not seem to know what the left had is doing at BCBS since it was my husband that made the evaluator look up the psychological evaluation that DID satisfy the behavior portion as he was told by her after she looked and saw it was there from the START 2-01-2011.  SORRY GETTING FRUSTRATED JUST TYPING MY LAP BAND STORY.  IT HURTS TO HAVE TO GO THROUGH ALL THIS.  So after all this effort and time on my husband and even on my part I sent a LONG letter going into detail to them also, on 6-02-2011 he is told that you have had three denials (no she is wrong more like 6, UNLESS you count by each separate item, but then it still was messed up.  He is told once you get three denials it is out of their hands and goes to appeal and my husband said no he is not going to accept appeal since all except the co-morbidities were NOT valid denials and they were not.  PLEASE NOTE BY READING "DUSTBUSTER-00" ORDEAL ALONE WITH THE MAKING HER JUMP THROUGH HOOPS FOR THE DIET PROGRAM AND SHE IS RIGHT THEY ARE VAGUE MY HUSBAND ASKED WHAT PROGRAM DO YOU APPROVE TO TWO PEOPLE AND THEY DID NOT ANSWER.  THE LETTERS THAT SEND OUT JUST SAY (GOING BY MEMORY) "THERE IS NO EVIDENCE OF ANY WEIGHT LOSS PROGRAM AND SOME OTHER FORM LETTER STUFF"  THE SAME THING WE ALL GET, AND JUST LIKE THE OTHER LADY ON THIS WEBSITE THEY ARE VAGUE AND IF YOU ARE HAVING PROBLEMS ALSO PLEASE SEND EMAILS BECAUSE IF THEY DON'T GET YOU ON THE OTHERS THEY CAN FIND ALL SORTS OF WAYS TO FIND TECHNICALITIES TO FIND SOME WHY OF DENYING YOU ON THE DIET PROGRAM ALONE.  THE LADY WAS ASKED BY MY HUSBAND TWICE WHAT THE LAST DENIAL LETTER WAS GOING TO BE ON AND SHE JUST KEPT TELLING HIM (THIS IS THE TRUTH) THAT IT IS IN THE MAIL (AS OF TODAY 6-8-2011 STILL HAVE NOT RECEIVED IT).  WHAT MORE COULD THEY FIND THAT THEY HAVE NOT HAD ACCESS TO SINCE 2-01-2011 AND HAD FROM THAT TIME ON TO DENY AND GIVE US A CHANCE TO PROVIDE THEM EVERYTHING THEY WANTED SINCE THE DATE ABOVE.  I AM HURTING AND HOPE THAT MY JOURNEY/STORY WILL BRING OUT OTHERS WHO HAVE SIMILAR EXPERIENCES LIKE "DUSTBUSTER-00" AND MYSELF.  I NOTICED THAT YOU FINALLY GOT APPROVAL AND I AM SO HAPPY FOR YOU, AND I THANK EVERYONE FOR ALLOWING ME TO SHARE MY STORY.  TAKE CARE AND BEST WISHES! :)