Blue Cross Blue Shield of Illinois PPO

[Ready2BDone 7]

Does anyone have the BCBS of IL PPO? I am really confused with this whole process. I met with my surgeon back in May. Then he told me that he wouldn't see me until one month before surgery. His office already had me do some testing, but it's my understanding that I am required to do the 6 months medically supervised diet. Can someone clarify this for me?

[Monica_Lynn 0]

I too have BCBSIL and yes they do require 6 months of medically supervised weight loss within the last 24 months. Along with that you have your psych eval and nutritional education (I did thru my PCP). I started this in January and at that time it was only 3 month but that changed in March They also require your BMI to be over 40 without co-morbidities or 35+ with 2 co-morbidities.

Once my 6 months was over my file was submitted and in 1 week I had an answer that they needed additional information. The additional information was faxed over by me on 8/17 and again by my surgeon's office on 8/18 and I received my approval on 8/25/11 but I did have to call to get the verbal approval.

I hope this information helps...Let me know if you have any other questions I can help out with. I studied the insurance coverage and requirements so there were NO surprises!!!

[favoredone 590]

Monica, has your surgery been scheduled yet??? I have BCBSIL... and I'm going through the Bariatric Center at Little Company of Mary... I was hoping to have my surgery during the holiday break (I teach high school Chemistry), but my pt. coord. thinks that's a lofty goal since my final appt w/ my wt loss spec isn't until dec. 10 (i think).. My break starts on the 17th... I already met w/ my surgeon (Dr. Gerald Cahill) and I'm going for an appt. w/ a pulmonologist this afternoon..

So, your post gives me hope that I can possible get a date for the end of year.. I hope so!!! LOL..

Blessings and good thoughts to you!!!

I too have BCBSIL and yes they do require 6 months of medically supervised weight loss within the last 24 months. Along with that you have your psych eval and nutritional education (I did thru my PCP). I started this in January and at that time it was only 3 month but that changed in March They also require your BMI to be over 40 without co-morbidities or 35+ with 2 co-morbidities.

Once my 6 months was over my file was submitted and in 1 week I had an answer that they needed additional information. The additional information was faxed over by me on 8/17 and again by my surgeon's office on 8/18 and I received my approval on 8/25/11 but I did have to call to get the verbal approval.

I hope this information helps...Let me know if you have any other questions I can help out with. I studied the insurance coverage and requirements so there were NO surprises!!!

[Monica_Lynn 0]

My surgery date is September 28. When I talked to the patient coordinator she said they were scheduling in October but when I got the call it was September 28. It all depends how far out your surgeon schedules.

[madamelp 0]

What they told you about the BCBS PPO approach is true. You have to be on a six month medically supervised diet before the surgery. You might lose weight, not lose weight, gain weight...there is no requirement other than the surgeon's office being able to say that you were on "a six month medically supervised diet". Then BCBS of Illinois will pay for the surgery. I don't want to wait six months and having any of the surgeries (lap band, gastric sleeve plication or gastric bypass) are less than half the cost in the Mexican hospitals. Plus, the Mexican doctors have more experience with the procedures. They have all done more and have been doing them longer. That is why I decided to go to Mexico and to pay for the surgery myself. Clinic in Chicago wanted $13K for the lapband vs. 4995 in Hospital Angeles Tijuana. They don't even offer the gastric plication surgery here yet. So, I am off to Mexico for surgery at the end of the month. I should be 60 pounds thinner before BCBS would even let me do anything.

[MeMeMEEE 206]

I have BCBSIL PPO and work for them. I was told specifically that 6 months medically supervised weight loss was 6 months of visits with your physician where you discuss your weight, what you are doing to lose during your 6 months, exercise/diet plan etc. I have heard of one person submitting 6 months of nutritionist visits and being approved. My Dr filled out a form my surgeon's office required each month and only submitted once they had all of those forms in hand. I was told specifically also that a weight watchers booklet showing 6 months of weigh ins doesn't count. Now, if you have discussed your weight and what you were doing to lose 6 times over 24 months your doctor could say you have met that requirement.

Here is a link directly to the medical policy -

http://medicalpolicy.hcsc.net/medicalpolicy/home?ctype=POLICY&cat=Surgery&path=/templatedata/medpolicies/POLICY/data/SURGERY/SUR716.003_2011-03-15#hlink

The statement below is pretty clear -

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.

[sweety93 18]

Monica you are right on point. You posted the medical policy to a T. I have a quick question I've been seeing my PCP for medical Weight Management....Did you see a nutritionist or did you receive nutritional counseling from your pcp?

[Monica_Lynn 0]

I did the nutrition with my PCP also and he had noted everything we talked about in his progress notes. So when I turned in my 6 months of notes everything was in there. Although we had to fax some pages twice I did get the approval 5 days after the 2nd fax.

[sweety93 18]

Awesome thank u lady

[Monica_Lynn 0]

Happy to help!

[Phat girl 6]

I have bcbs but it's trs TX. My medical policy reads the same about the documentation on non surgical weight management for 6 months. I was denied the first time with my Weight Watchers documentation but appealed it with medical review. I won. Weight watchers IS a nonsurigcal program of weight reduction. It took one day after medical review to be approved. My doctor was ready for surgery the next week.

[MeMeMEEE 206]

Let you in on a secret - IL TX NM and OK are all under Health Care Service Corporation so they would be similar med policies That is so awesome you got approved with weight watchers! I have always heard they wouldn't.

I have bcbs but it's trs TX. My medical policy reads the same about the documentation on non surgical weight management for 6 months. I was denied the first time with my Weight Watchers documentation but appealed it with medical review. I won. Weight watchers IS a nonsurigcal program of weight reduction. It took one day after medical review to be approved. My doctor was ready for surgery the next week.

[Phat girl 6]

Thanks! It was an uphill fight but the policy does not say physician supervised. That's just something they like to say when they want to deny you. They even called my pcp and tried to get her to say I hadn't been compliant with Weight watchers. Crazy!

[sweety93 18]

The key is to fight. I to work for a major insurance company but I am also a member and I understand the importance of being insistence and standing firm. I'm getting excited and ready

[sweety93 18]

Congrats Phat for being proactive