Tammy M

Hello all, First post, but unfortunately I am frustrated. I know this is the holiday season, but I am sick of bl/bs of IL PPO. I am at a 40 BMI. I found out that they denied my claim? WTF? All I read about here is how quickly bc/bs approves surgery. The insurance guy called and said it was denied because I have no behavior modification program. Funny, the nutritionist talked to me specifically about behavior modification. I was 130 pounds and ran 5 and a half miles a day for over 20 years, and I ate well. I got hurt at work 3 years ago and gained almost 100 pounds. Also they bc/bs guy said I have no exercise plan. Right this second I cannot exercise because of my back and knees. As soon as I lose weight, this may give me a chance to exercise. Unnfortunately, I'll never be able to run again because of a knee replacement. I can join a gym. The last thing the insurance guy said that I have no support plan. I am going to a lap band support group if they approve this. If I have to join Weight Watchers, I will. My doctor's medical records person is not dumb. She should know if bc/bs required that information. I think bc/bs just wants to deny it not to have to pay for it. Oh my husband's company is looking at other insurance companies, so I may get approved and not have that insurance any longer. I am beyond pissed. Do any of you think I should continue to push this with my insurance company, or is a denial a blanket denial?

That really sucks. I don't have the money to self pay. If you not at a 40 BMI, most insurance comanies won't approve it.

I would love to see your pictures, but my laptop won't let me view it.

Well, after waiting a whole week, my surgeon's office was finally open. They refaxed all the information to my insurance company. Blue cross is now requiring certain verbage in the letter that my surgeon sent to the. Now they requiring the the surgeon to include in his letter attesting basically everything that the dietician talked to me about. This is really redundancy. The medical records lady, Pricilla said she as 4 patients that were waiting for that exact letter. Unforunately, my surgeon doesn't come in until Friday. I'm sure he will write exactly what they're now requriing. So I feeling my better that this letter will get me approved. Hopefully I'll have good news to report soon.

How right you are. I spoke to my insurance company today. They received no information from my dietician about pre and post op requirements. No modification information, and no exercise plan. My dietician discussed all of this with me. WOULD YOU BELIEVE SHE SUBMITTED NOTHING? Also my surgeon dropped the ball. They need a letter from him as to why the lap band is a medical necessity. We discussed my high blood pressure, my borderline diabetes, my arthritis, my cholesteral, and my family history. WOULD YOU BELIEVE HE SUBMITTED NOTHING? They also want to know that I will get counceling. I see my Psychiatrist once a month. In fact he was the one who submitted the letter saying that I was mentally prepared for the surgery. I am not sure if that is enough. They may want me to receive weekly counceling, but I forgot to ask my bc/bs rep that. :angry: :angry: :angry: :angry:

.Too late,I am already discouraged. Of course all of the crap happened over the holidays. So I won't be able to get in touch with anyone until Wednesday. The other concern I have is that my husband's company is looking into changing insurance companies. So if I plan to use bc/bs to cover this, I have to do it quickly. Day One Health is basically on Michigan Ave in Chicago. I researched it before I chose them. I really think they dropped the ball on this. It seemed like I was kind of being bum rushed because my appointment was late on Friday and everyone wanted to be off for the for the holidays. They closed the office until after New Year's Day. I remember two things my bc/bs rep told me was I did not have a behavior modification program. That is exactly what the dietician discussed with me. I had no exercise program. That is my point. I am injured and that's what made me gain the weight. Worker's comp will not cover anymore treatments. So I am going to court for a settlement. When I receive a letter from Traveler's Insurance saying they will not cover more treatments. I will be able to go thru bc/bs to help my back. My pain management doctor says losing weight will really help my condition. I told my dietician that. She wrote something down. If that was going to be a problem, she should have talked to me about it and encourage me to at least walk 30 minutes a day. The other thing I "think" my bc/bs rep said they need blood tests results. Has anyone had to submit a blood test to bc/bs? If not, I misunderstood him. Someone on this board suggested I join a gym or go to the YMCA That was an excellent suggestion. I can cancel that after surgery.. Thanks to all of you that responded to my post.

Hi everyone, I am so glad I found this site. This has already given me valuable information. I am hoping to get the lap band surgery. My BMI is 40 and I have comorbities. All my life I've weighed 130 pounds and ran 51/2 miles a day for over 20 years. In 2009 I got a severe back injury at work. Also, I was fired about a year later because I couldn't work as hard. I've gained almost 100lbs. Worker's Comp has screwed me for three years. I have a lawyer and we will be going to court soon. I believe I will get a good size settlement. I deserve it. I just found out bc/bs of IL denied my surgery. I am not sure it was an out and out denial. They said I didn't have documentation of a behavior modification program. Yes I do. I met with the dietician and we set goals. They wanted to know about my exercise plans. They also wanted what plan I was going to use, like Weight Watchers. I simply plan to join a lap band support group.. The one thing they didn't ask me about was any blood tests. I am going to call the insurance lady at the doctor's office in Chicago to find out why she didn't include all the information my insurance needed. She assured me at my consultation that she worked with bc/bs all of the time and knew how to submit the correct information. Either she did not do her job, or bc/bs of IL doesn't want to pay for my surgery. Tammy M

Luckily my brother in law owns the company. He would never fight to keep me from getting the surgery.

No, I told the clinic that a formal exercise program would be difficult for me because of my worker's comp back injury. I told her my doctor said if I could lose weight, a lot of my pain will improve and I may be able to exercise. I am just going to do what Missy said and join a health club.

I'm not giving up. My life depends on this. I just don't understand why most people breeze through the approval process through bc/bs of IL PPO, and I am having a hard time. Sorry to be so whiney. I'm just afraid my husband's company may drop bc/bs soon. I need to get this surgery done asap. These holiday hours are really putting me behind. No one is working this week apparently.

bc/bs said they needed to know what kind of weight management program I would be on after surgery. Bc/bs could have just said that thinking I won't appeal this so they don't have to pay for it.

I am not talking about a weight management program before surgery. Yes, all insurance companies were mandated to stop that requirement in Feb. 1, 2012

Day One Health Center is where I plan to go if approved.

Thanks for answering, but apparently bc/bs of IL does require a weight management. They did not even mention blood test. I have the psych eval and sent that to them. You are right, the dietician did talk to me about behavior modification. Ank how can I prove to them I will exercise?