I just can't believe it!

[SassyTink 78]

Right now I am so devastated I can barely type. My process began on March 20 2013, when I notified BCBS of Illinois concerning Bariatric Surgery. Below is a copy of the correspondence:

03/20/2013 18:44:00 -- Member Question:

Hello

Unfortunately, at this time I am looking into Bariatric Surgery at the recommendation of my internist. We have a Blue Distinction Bariatric Center in Portland. What are the different steps that Blue Cross requires, under my plan for this surgery.

Response:

Bariatric Surgery

03/21/2013 15:12:31 - HCSC Response:

Hi Patrice,

Surgical treatment of morbid obesity may be considered eligible for coverage when all of the physical, clinical and psychological indications are documented according to Blue Cross Blue Shield of Illinois current medical policy. A letter of support and/or explanation is helpful but alone will not be considered sufficient documentation to make a medical necessity determination.

We are not in a position to consider the request for surgical treatment of morbid obesity due to the lack of available medical documentation to determine medical necessity based on Blue Cross Blue Shield of Illinois medical policy. The following documented clinical information is necessary for further review.

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/meter (* see guidelines below for BMI calculation); OR

- BMI equal to or greater than 35kg/meters 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:

o Hypertension, OR

o Dyslipidemia, OR

o Diabetes mellitus, OR

o Coronary heart disease, OR

o sleep apnea, OR

o 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.

The member and their physician(s) are urged to review the full text of the Blue Cross Blue Shield Illinois (BCBSIL) medical policy on this subject on the BCBSIL Website at www.bcbsil.com. Choose the "provider" link at the top of the Website and select medical policies: Surgery for Morbid Obesity (search by policy title).

If you any further questions or concerns, please contact our customer service department at the toll-free number on the back of your Blue Cross Blue Shield identification card or via the Message Center on Blue Access for Members.

Sincerely,

Cheryl M.

Blue Cross Blue Shield Illinois

Customer Service Center

For the last six months I have seen the Bariatric Centers Dr's, nutritionist, physical therapist, psychologist and 80% of every appointment was covered by my policy. I have pain my 1500.00 out of pocket expenses and ready to go. Today I found out that my insurance policy has an exemption on Bariatric Surgery.

WHAT?????? The insurance company gave me the info above and paid all of the pre surgery visits.

I assumed the Dr's office did their job,

• Submit an electronic Eligibility & Benefits Inquiry (ANSI 270 transaction) to BCBSIL through your preferred online vendor portal.
  

Now I am left disappointed and totally depressed. I just can't understand how this happens.

[VSG AJH 499]

I don't even understand how something like that could happen. I am so, so sorry.

[greersc 58]

Check on an attorney...don't give up

[barbarahadz1 84]

Did you get the exemption information in writing? You can call 5 times and get 5 different answers

There should be health care advocates available to help you With my insurance the advocate information is listed on the back of the EOB (explanation of benefits they send you file a claim)

[loveelaura 52]

Your surgeons office should have checked before you even started the process.. That is seriously messed up!

Sent from my iPhone using VST

[SassyTink 78]

I spoke to the Bariatric Center again this morning. Apparently, they have a letter dated March 20, 2013 from BCBS giving the okay for the Bariatric process. The Dr's office did everything 100% correctly according to their notes. Now, we play the blame game as to who is in the right here.

Is the insurance company game playing or is the Dr's office? I will soon find out. My intuition is the Dr's office did everything by the book and the insurance company screwed up. Why would BCBS pay 6 months of pre bariatric surgery appointments if I wasn't covered? The plot thickens. I am going to have my surgery this month.......regardless of who screwed up. They have to make this right. Beware!!

[dlar57 29]

I had to get 5 years of weight documents on weight watchers. Jenny Greg la fitness? That I try to loose weight. I started in June , I had nutrition which they don't pay for, I got a letter from doctor , cardiologist, gastriiogist, upper gi ,blood work , they send it to insurance I was approve for nov19 the doctor gives you a list of stuff that has to be done it takes time good luck

[SassyTink 78]

YOU ARE NOT GOING TO BELIEVE THIS. My policy does not have an exclusion for bariatric surgery. BCBS of Illinois admitted that my denial was a MISTAKE. BCBS is now going over my file and an approval should be coming within 24 hrs. They apologized for the error, will re-evaluate my request for surgery and hopefully get back to me quickly. The Dr's office has also been informed by me that I want my surgery scheduled as soon as they get the approval. ENOUGH IS ENOUGH!

WHAT A JOKE. It looks like the last 24 hrs of torture were a character building experience. I don't have the approval yet, but am confident it should be forthcoming.

Prayers really do work. I thank everyone of you who sympathized with me. Your responses of support were really helpful. Again, sincerely, I thank you.

Me

[VSG AJH 499]

YOU ARE NOT GOING TO BELIEVE THIS. My policy does not have an exclusion for bariatric surgery. BCBS of Illinois admitted that my denial was a MISTAKE. BCBS is now going over my file and an approval should be coming within 24 hrs. They apologized for the error' date=' will re-evaluate my request for surgery and hopefully get back to me quickly. The Dr's office has also been informed by me that I want my surgery scheduled as soon as they get the approval. ENOUGH IS ENOUGH!

WHAT A JOKE. It looks like the last 24 hrs of torture were a character building experience. I don't have the approval yet, but am confident it should be forthcoming.

Prayers really do work. I thank everyone of you who sympathized with me. Your responses of support were really helpful. Again, sincerely, I thank you.

Me[/quote']

What WONDERFUL news, Tink! I'm terrified of added drama during this process -- drama just like this. SO HAPPY everything seems to be moving in the right direction. Thanks for the update!

[Sherbear34 0]

Wow! What an emotional roller coaster! Congrats on getting the answer you were looking for! I'm a prep as well waiting for my tax return to go to Mexico as a self pay. However we get there what's important is that we get there.

[shondaj 14]

congrat i to have bcbs of Illinois and had no problem getting my surgery good luck and keep us posted

[ualaw08 270]

Congratulations!! What a roller coaster!! Good luck.