Insurance Denied !

[dustbuster_00 0]

I contacted Blue Cross Blue Shield of Illinois today to check the status of my request for coverage. I was told that I was denied due to a lack of documentation of the 6 month required diet. The only thing that the insurance company requires is Documentation of active participation in a comprehensive, non-surgical program of weight reduction for at least six (6) months, occurring within the twenty-four (24) months prior to the proposed surgery.

They say they accept a recognized commercial diet-based weight loss program. I gave them copies of invoices from two months of Nutrisystem and 6 months of invoices from Weight Watchers. Now I am pretty sure both of those are recognized commercial weight loss programs. So why am I being denied? It just does not make sense.

They have medical records from a Physician who was treating me with weight loss medication for three months.

I have seen a nutritionist.

I have seen the psychologist.

Anyone have any suggestions for me? PLEASE HELP

[NoMoBand 278]

BCBS has a appeal process. They do here in NM anyway. Find out and submit an appeal. I would go through your PCP and get her/his help with the appeal. BCBS of NM, puts a heavy weight on whatever the PCP reports to them with their recommendation for WLS. I'm sure each BCBS in each state is different, but, definately look into the appeal process. Good luck to you and don't get discouraged. Jake

[mjo3393 0]

You may want to check with your ins company. I know for me I had to go through the 6mn waiting, and get weighted in by my bariatric Dr. each month, and that is what my ins considered as my 6mn documented weight loss program. I could not use weight watchers or any of those, however they did want me to show that I have tried other ways to lose weight in the past. So again check to see if they want you to be seeing a bariatric doctor for your 6mn weight loss program. Good luck!

[Cocoabean 430]

Each insurance company has an appeals process. DO appeal. I have BCBS California HMO. I was denied even getting a consult because I hadn't done the 6 month thing.

I submitted WW records and other stuff like you did and won the appeal.

My PCP said a denial the first time around was pretty standard. However, for me, it was the medical group that denied it, NOT the HMO. I don't really understand the intricacies there.

Look at your plan brochure, your appeals process will be in there. As another poster said, ask your PCP to write a letter, if he or she suggested you do WW or nutrisystem ask that this fact be included, then you can state it was medically supervised. Even if your PCP doesn't write the letter, state that your doc recommended you lose weight, and said that WW is an excellent plan--so you did as your doctor suggested and joined.

Include a copy of your plan policy that states a commercial program is acceptable, just to remind them, they administer several different policies with different exclusions.

Hope this helps! Best wishes.

[dustbuster_00 0]

Thanks for all the tips these will really help when I file the appeal. I have already submitted copies of my Weight Watchers and Nutrisystem invoices for 8 months. I will contact my PCP to have him write another letter stating that he recommended Weight Watchers and supervised my weight loss. If anyone has any other suggestions for me please let me know. It is like getting kicked back down when you are already so motivated to start this new journey.

The Insurance companies are crooks. I pay my premium every month to ensure I have good insurance. They get to sit behind a desk and make decisions on whether they are going to pay my bills or not. I wish I could choose when to skip my monthly premium and still keep my insurance.

I am not going to give up that easy when I am so close. I meet all of their criteria. I just need them to follow their guidelines and approve the surgery.

[Rachel412 116]

I also have BCBS (different state) that requires a 6 month wait period. I had to submit records from my wls program, AND I had to submit 6 months of food logs. I would imagine just invoices aren't enough because you're not proving you ATE the right way? While you did WW did you keep your journals?

[cat lady 10]

Definately appeal.....I got denied by BCBS and won my appeal. It is discouraging after you did all they asked. I was denied bcause they said my high blood pressure was not considered a co-morbidity. I had my three doctors write letters to support my appeal. I attached documents showing how my HBP could be helped by this surgery.

I was so glad to be approved. Planning to do this in July when I have vacation time. Good Luck with your appeal.....I'm sure you will be successful. Don't give up.

[dustbuster_00 0]

I also have BCBS (different state) that requires a 6 month wait period. I had to submit records from my wls program, AND I had to submit 6 months of food logs. I would imagine just invoices aren't enough because you're not proving you ATE the right way? While you did WW did you keep your journals?

I did my Weight Watchers online and kept a food journal on there. Unfortunatly after you stop subscribing to their program, you are unable to retrive those documents. I keep track of my food and weight with "myfitness pal" online. This program allows you to print off food journals and notes. I will print those off and make sure they are complete and submit them to the insurance.

My Primary Doctor recommended Weight Watchers when I did it, but he failed to document any of this in my medical records. My Primary Doctor's office also failed to weigh me but only a few times in the past 5 years.

I was wondering if my doctor signed a weight log for the time I was doing Weight Watchers and submitted that as well if that would help?

[mattie7632 24]

You need to ask bcbs EXACTLY why it was denied. You will just be wasting your time until you have all the facts. Get the rep to tell you exactly what you didn't provide, or what documentation was not good enough and THEN you can get what they need. It will do you no good to go thru appeals if you don't even know what you are appealing. Good Luck!

[Cocoabean 430]

One other thought came to mind. When you did weight watchers or nutrisystem, was it for 6 months consecutive? I imagine it was, but if you did 3 months of WW then took a couple months off, then did 5 months of nutrisystem, they might take issue with that.

All I submitted for WW was my attendance books. I did traditional meetings. So it had the dates of the meetings and my weight. I did not give them food journals, but the myfitnesspal stuff is a great idea!

[dustbuster_00 0]

One other thought came to mind. When you did weight watchers or nutrisystem, was it for 6 months consecutive? I imagine it was, but if you did 3 months of WW then took a couple months off, then did 5 months of nutrisystem, they might take issue with that.

All I submitted for WW was my attendance books. I did traditional meetings. So it had the dates of the meetings and my weight. I did not give them food journals, but the myfitnesspal stuff is a great idea!

Yes I did WW for 6 consecutive months with no break.

[ericanda1973 1]

I got denied too ,I appealed thru obesitylaw.com and they won it for me. And the lap band company paid for them to appeal for me, if i chose lapband over realize band , if you appeal and DON'T give up they will eventually approve you. Good luck in your insurance dilemma.

[dustbuster_00 0]

Denied again! After sending BCBS IL 122 page daily food journal with weekly exercise at least 3 times a week, and weekly weight in, and a letter from my Primary Physician stating that he recommended Weight Watchers for the sixth month time period that I was on it. They are saying that is not enough proof of a comprehensive medically supervised diet and increased exercise. HOW MUCH MORE COULD THEY ASK FOR? They state in their medical policy for coverage that Weight Watchers is an approved commercial weight loss program. They have a copy of my Weight Watchers invoices from that time as well. This is really starting to irritate me. I feel like just giving up. Maybe this is not for me.This is the second time that they have denied me because of lack of documentation, but they will not tell me exactly what they are needing. Can anyone help me?

[Cocoabean 430]

Denied again! After sending BCBS IL 122 page daily food journal with weekly exercise at least 3 times a week, and weekly weight in, and a letter from my Primary Physician stating that he recommended Weight Watchers for the sixth month time period that I was on it. They are saying that is not enough proof of a comprehensive medically supervised diet and increased exercise. HOW MUCH MORE COULD THEY ASK FOR? They state in their medical policy for coverage that Weight Watchers is an approved commercial weight loss program. They have a copy of my Weight Watchers invoices from that time as well. This is really starting to irritate me. I feel like just giving up. Maybe this is not for me.This is the second time that they have denied me because of lack of documentation, but they will not tell me exactly what they are needing. Can anyone help me?

Ok, Here's more for an additional appeal. In 1991 the NIH put out a consensus about the surgical treatment of obesity. They did not mention a supervised diet as part of the criteria for patient selection. The article is here: http://consensus.nih...sity084html.htm

Those patients judged by experienced clinicians to have a low probability of success with nonsurgical measures, as demonstrated for example by failures in established weight control programs or reluctance by the patient to enter such a program, may be considered for surgery.

Another statement came out in 2004 from the American Society of Bariatric Surgeons. http://www.asbs.org/...e_Statement.pdf

"Bariatric surgery candidates should have attempted to lose weight by nonoperative means, including self-directed dieting, nutritional counseling, and commercial and hospital-based weight loss programs, but should not be required to have completed formal nonoperative obesity therapy as a precondition for the operation.

So, you have done as much or more than what the National Institutes of Health and the American Society of Bariatric Surgeons say should be the standard diet attempts for patient selection. Find out what the next level of appeal/review is in your state. Your policy should have it written within. FIGHT for yourself. They want you to give up.

[xavier 153]

They want you to get frustrated and quit...many people do and it save the insurance companies a ton of money. Dont give up!!!