Blue Shield Denial - so upset

[Olarance75 215]

Just hang in there. Everything will work out and your time will come. My primary gave me the run around for three months after he wrote my letter of support. He would not release my medical records. I continued to go to his office weekly, wrote letters requesting my records and paid additional office visit copays. It was nightmare and I thought I was going to need to find new Dr and start diet documentation all over. Finally on 8/27y Bcbs had to intervene to get my medical records released to the surgeon. He complied and sent to surgeon the very next day. I am now waiting on surgery date. So I would suggest that you request in writing for utilization review at bcbs the requirements. You have vented and now its time to move forward. Stay on top of everything. Schedule appointments with your primary and the dietian for this month and get started. Your goal is to have all 6 visits finished by first week of Feb.

[LipstickLady 25,682]

It's not the insurance company's fault. And no, I do not work for one.

WE are responsible for knowing the requirements. Your employer decides what is covered and what is not covered along with how long you must wait pre-op. They pick which package they want to pay for. The insurance company is simply following the guidelines that that are set out by the company who is providing the benefit.

Some BCBS plans have no wait, some have 3 months (mine), some 6 (my last company), some a year (our county schools), some 2 years (the neighboring county schools) and some have no coverage at all (my BFFs). We are all BCBS.

[kayel8ch 1]

I just got off the phone with the union, and they said that I can do my 6 months with the PCP, but it must be consecutive! I didn't have consecutive before. And then I would need my psych eval, which is $500 btw. Then resubmit.

Now if I do the requirements for the insurance I'm ready to go. BUT then what about the bariatric program requirements. Would I need to satisfy that also?

Guess I need to make some more phone calls.

[Olarance75 215]

My surgeons program didn't have any additional requirements for me to follow. I believe that depends on individual and your medical status. Follow up with your baratric program coordinator to determine what else outside of the insurance requirements is the surgeron requiring from you. i know some people have been required by their surgeron to loss x amount of weight before they will perform the procedure

[kathp 81]

I didn't see the doctor every month, but I was MEDICALLY supervised by the dietician every month, and the surgeon's office met to go over the case files at least monthly. So there may be room in that respect, as long as it's CONSECUTIVE months. I know they're a real stickler on the consecutive visits.

[Breesmom813 0]

We checked our package and read through the entire guidelines and it says nothing about bariatric surgery. Yes, I vented, and with good reason. I do blame insurance companies. They are misleading and do whatever they can to weasel out of actually paying for anything. I lost 15 lbs under a diet set forth by my nutritionist. I say that's more telling than 6 months consecutive.

It's arbitrary and trite and bs.

Ok now I'm done venting. I have a dietician appt next week and still waiting on pcp appt. Shes very hard to get appts with.

[Breesmom813 0]

I was required by the surgeons office to have blood tests, 2 x-rays, an EKG, sleep study, psych Eval, dietician appts and lose 15 lbs, all of which I completed.

[Olarance75 215]

The medical policy that the insurance companies use isnt misleading. for bcbsm of mi the policy clearly states 6 consecutive months uder dr supervised care. A dietitian is not a medical doctor.. They only monitor your food intake. Whereas a medical Dr. Also sends you to other specialists like cardiology to ensure enverything is ok. Your going to need cardic clearance and surgeon doesn't refer you for that

[Olarance75 215]

When was last time you saw Dr.

[Reviewer 20]

Today I finally received the date of my first appointment. Included in the email were the insurance requirements. They are listed below. I'm not sure how I'm going to go about providing evidence of failed weight loss attempts. I've never done WW or any other type of supervised weight loss. I've always lost weight (and gained it back) on my own. Or will the medically supervised program I'm about to start satisfy that requirement? Any advice?

Blue Cross Blue Shield Insurance- Federal Surgical Weight Loss Requirements

-​BMI ≥ 40 or BMI ≥ 35 with co-morbidities who has failed conservative treatment.

-Participation in a medically supervised weight loss program, including nutritional counseling, for at least 3 months prior to the date of surgery.

-Evidence that attempts at weight loss in the 1 year period prior to surgery has been ineffective.

- Psychological Evaluation

-Patient has not smoked in the 6 months prior to surgery

-Patient has not been treated for substance abuse for 1 year prior to surgery

- Two years of obesity history

[Olarance75 215]

I filled out weight watchers food journals and turned those in to show previous weight loss attempts. Also I work for Bcbs and they paid for my weight watchers as well as my medical weight loss. We pay out of pocket and submit for reimburstment aspart of our yearly employee allottment for healthy living. Let me do some research tomorrow with couple of friends who had procedure to see what they used

[LipstickLady 25,682]

All I had to do was write a list of all the things I've tried. WWs, Atkins, South Beach, Phentermine, doctor supervised, nutritionist. No actual documentation was submitted, but just a estimate of time frames and outcomes of each.

[youthguy80 65]

Today I finally received the date of my first appointment. Included in the email were the insurance requirements. They are listed below. I'm not sure how I'm going to go about providing evidence of failed weight loss attempts. I've never done WW or any other type of supervised weight loss. I've always lost weight (and gained it back) on my own. Or will the medically supervised program I'm about to start satisfy that requirement? Any advice?

Blue Cross Blue Shield Insurance- Federal Surgical Weight Loss Requirements

-​BMI ≥ 40 or BMI ≥ 35 with co-morbidities who has failed conservative treatment.

-Participation in a medically supervised weight loss program' date=' including nutritional counseling, for at least 3 months prior to the date of surgery.

-Evidence that attempts at weight loss in the 1 year period prior to surgery has been ineffective.

- Psychological Evaluation

-Patient has not smoked in the 6 months prior to surgery

-Patient has not been treated for substance abuse for 1 year prior to surgery

- Two years of obesity history[/quote']

For the three months, they don't specify nutritional counseling with a nutritionist. Seems like nutritional counseling with your dr would suffice, as long as its documented in your chart by your dr. And I would see the dr at least once a month in those three months just to be safe. From experience (six month insurance requirement), any work you do to prepare for the new way of living will pay off for you in the end.

[Breesmom813 0]

Can someone please tell me where I was supposed to find the 6 month requirement. I just looked over my entire summary of plan benefits and coverages of which it only says bariatric surgery is covered but for more info check plan document and policy. Read the entire evidence of coverage/policy and not a word about bariatric surgery. When I called, the info was not given to me. So can someone please tell me how this is my fault and not insurance? How did you all find out?

[youthguy80 65]

Can someone please tell me where I was supposed to find the 6 month requirement. I just looked over my entire summary of plan benefits and coverages of which it only says bariatric surgery is covered but for more info check plan document and policy. Read the entire evidence of coverage/policy and not a word about bariatric surgery. When I called' date=' the info was not given to me. So can someone please tell me how this is my fault and not insurance? How did you all find out?[/quote']

Mine was not in the benefits book provided by my employer. It was on the insurances website under "Medical Policies." Member services should be able to read it to you, tell you where to find it and how to access it. If not, they are not doing their job.