Bcbsil: Denied 1St Time. My 2Nd Attempt

[JSahi 6]

I was denied earlier this year by bcbsil. I can not remember the exact reason but I believe it was because I had no major health issues, besides my weight. But I have had some bothering issues since then and also want to try again. I was wondering if anyone went through this (being denied) and got approved the 2nd or 3rd time around, if so what did you do? I havent applied/signed up yet. Attending seminar on the 24th.

(bcbs members would be awesome to reply back but anyone else is more than welcomed if had similar problem)

[mybella 35]

I have BCBS of Massachusetts. I was only 100 pound over weight and no underlying condition when I started this journey. During my test, they found out I had a Hiatial Hernia which I thought was very bad heartburn and sleep apnea which I never thought I had that either. My question to you did you get the sleep study and the upper gi done? Do you have high blood pressure or diabetes? Any of the above is a condition that they will not deny me. At the begining, I had the weight and both sides of my family has high blood pressure and diabetes and kidney failure, so I though that was enough according to my dr, but I ended up with condition which was the hernia, and sleep apnea.

I heard that BCBS has changed it policy in the last 6 months so I would check with you insurance company and if you have not had the sleep apnea or upper gi test see if your dr will give it to you. Sleep apnea is a condition from overweight so you may have it and not realize it just like me. Is your BMI over 40 because mine was and that is why I started this journey and that you have gone on multiple diets. Good luck

[JSahi 6]

Yes I have a history of high blood pressure and my dad side of the fam has a history for bad hearts and weight problems. My bmi is also over 40. I am not sure what my previous doctor sent them to look at because I thought they would of,approved me. I have to change doctors at the same clinic so I will see what this one has to say as well. Also thank you. Your infomation is very helpful.

[mybella 35]

_{Your welcome, but you can call member services on he back of your BCBS card and they will give you information. They were vague, but they did tell me if my doctor feels I qualify I will be approved and BCBS does cover the WLS. So you may do better with another doctor, but did you get the sleep study and the upper GI test?}

[JSahi 6]

Ok and nope not yet. I will ask the doctor when i go back to the clinic to make an appt for the test.

[Lapbandster 496]

I have BCBS of iowa (otherwise known as wellmark) even though I'm from illinois (my company is based out of iowa...)

Anyhow, I was also denied my first attempt. Then I did the 6 month diet, did all the preop testing (total hell), and FINALLY was approved!

My advice: work with your surgeons coordinator to help you with the submitting process. they do this all the time and know all the nuances and things you need to get approved

Good Luck

[ChicagoRose 650]

I am also in bcbsil. There is a lot of hoops to jump before you get the ok and it may take up to a year. I am on month 6 of visits with our dietitian and have not seen the surgeon or bariatric center yet which is phase 2... maybe you are too early in the process?

[JSahi 6]

I'm not sure. My cousin had lap band who is also with bcbsil and she didnt have to go through much. She also didnt have major health issues, just over 40 with the bmi. She was approved within 2 weeks after they sent her info to the insurance company. Similar with a friend of the family. She was approved pretty fast.

[missmudd 17]

I had BS of ID and was denied because I had no official diagnosis of Diabetes even though I had gestational diabetes twice with both pregnancies and high cholesterol. They required certain 'comorbidities', not just the ones listed on the FDA website, in addition to BMI 35+. And I was also denied because I had not fulfilled 2 yrs of doctor-supervised weight loss with proven weight loss. I was just tired of trying to jump through the hoops to have it covered. I even work for them! Anyway, i'll be able to claim the expense on taxes as non-covered medical since I meet the FDA criteria. I'd suggest filing your 'appeal' with supporting documentation (submitted by your surgeon/pcp) and go from there. Have the doc write a letter also. This is taken straight from the BCBS of IL website for providers regarding medical policies in place for certain procedures that require preauth. This is for bariatric surgery.

http://medicalpolicy.hcsc.net/medicalpolicy/home?ctype=POLICY&cat=Surgery&path=/templatedata/medpolicies/POLICY/data/SURGERY/SUR716.003_2012-02-01#hlink

NOTE: Check member’s contract for benefit coverage for bariatric surgery.

PATIENT SELECTION CRITERIA FOR COVERAGE

For a member to be considered eligible for benefit coverage of bariatric surgery to treat morbid obesity, the member must meet the following two criteria:

1. Diagnosis of morbid obesity, defined as a:

• Body mass index (BMI) equal to or greater than 40 kg/meter² (* see guidelines below for BMI calculation); OR
  
• BMI equal to or greater than 35kg/meters² with at least two (2) of the following comorbid conditions related to obesity that have not responded to maximum medical management and that are generally expected to be reversed or improved by bariatric treatment:
  
  • Hypertension, OR
    
  • Dyslipidemia, OR
    
  • Diabetes mellitus, OR
    
  • Coronary heart disease, OR
    
  • sleep apnea, OR
    
  • Osteoarthritis; AND
    

2. Documentation from the requesting surgical program that:

• Growth is completed (generally, growth is considered completed by 18 years of age); AND
  
• Documentation from the surgeon attesting that the patient has been educated in and understands the post-operative regimen, which should include ALL of the following components:
  

1. Nutrition program, which may include a very low calorie diet or a recognized commercial diet-based weight loss program; AND
   
   
2. Behavior modification or behavioral health interventions; AND
   
   
3. Counseling and instruction on exercise and increased physical activity; AND
   
   
4. Ongoing support for lifestyle changes to make and maintain appropriate choices that will reduce health risk factors and improve overall health; AND
   
   

• Patient has completed an evaluation by a licensed professional counselor, psychologist or psychiatrist within the 12 months preceding the request for surgery. This evaluation should document:
  

1. The absence of significant psychopathology that would hinder the ability of an individual to understand the procedure and comply with medical/surgical recommendations, AND
   
   
2. The absence of any psychological comorbidity that could contribute to weight mismanagement or a diagnosed eating disorder, AND
   
   
3. The patient’s willingness to comply with preoperative and postoperative treatment plans.
   
   

COVERAGE STATEMENTS FOR SPECIFIC BARIATRIC SURGICAL PROCEDURES (Gastric Restrictive and Gastric Malabsorptive)

NOTE: For a member to be eligible for benefit coverage of any one of these procedures the member must meet the Patient Selection Criteria described above AND the member’s contract or certificate of coverage must allow coverage of bariatric surgery.

• Adjustable gastric banding (open or laparoscopic), consisting of an external adjustable band placed high around the stomach creating a small pouch and a small stoma, may be considered medically necessary as a surgical treatment option for patients with morbid obesity who meet the eligibility criteria for surgery, including lack of response to the required conservative measures.
  

NOTE

: If the original adjustable gastric banding procedure was a covered benefit, it is not necessary to request documentation for refill and maintenance procedures.

[NettaRue 4]

I have bcbs of Illinois and had no problem getting approved. My bmi was 39 and I had slight high blood pressure, that's all. I know the policy used to call for 6 months of nutrition counseling but now only requires one month after February 1st. Maybe it's how your doctor submitted the paperwork.