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.

[Rena's got this 274]

I would contact them again and ask them when they stopped covering bariatric surgery. Maybe you can get "grandfathered in" if it was after the date of your letter to them. Be the squeaky wheel and don't let them off the hook!

[Beach Lover 1,084]

Go back to the insurance coordinator and have them fight for you. This doesn't make much sense it seems like someone left something out along the way. Ask them what documentation have they sent to your insurance company. This sounds like the medical office may have left some things out. Good luck to you and fight for it!!

[SassyTink 78]

BCBS said there has always been an exclusion on my policy. "An exclusion is an exclusion and can not be covered!!" The reply I got from them six months ago was generic, per the BCBS associate I spoke to. The Dr's office also dropped the ball. They should have done the eligibility inquiry like they were supposed to. It seems like the insurance and the Dr's office were remiss. I did everything by the book. This is awful. I just can't wrap my head around this. So sad, I wanted this so badly.

[Inactive Profile 104]

Oh sweet heart I am very sorry, I had 2 years of the same things..... Just keep going, don't give up, there will times you are ready to throw your hands up and walk away ( I did for 4 months and the came back and started back). Just keep trucking. Also look into groups that help pay for it. I know how disheartening this is and I feel so deeply for you.

Edited November 4, 2013 by DreamBig

[Seela 1,187]

Do NOT assume your Dr office fid everything right.. there was an error in faxing my documents that resulted in a delay. As a center of distinction they would not have had you go through all that if they weren't confident you would be approved. Keep calling both the ins and Dr until you figure out the missing piece. Try to be patient. .. your doing everything right and it will happen. Don't give up! !

[Seela 1,187]

Oh God, I am so sorry. I still wouldn't drop it. You have a letter from them with all of your info on it stating they would covrr it if... I would fight it.

[Ms.AntiBand 2,984]

Don't stop or give up. At the least you can fight for reimbursement for unnecessary testing and diagnosis procedures you endured as their requirements etc.

You won't be covered for surgery because that's written in your policy. Nothing can be done about that, but fight for your reimbursement.

So sorry you experienced the nastiness of the ol' faithful insurance company.. I personally despise them

[Beach Lover 1,084]

BCBS said there has always been an exclusion on my policy. "An exclusion is an exclusion and can not be covered!!" The reply I got from them six months ago was generic, per the BCBS associate I spoke to. The Dr's office also dropped the ball. They should have done the eligibility inquiry like they were supposed to. It seems like the insurance and the Dr's office were remiss. I did everything by the book. This is awful. I just can't wrap my head around this. So sad, I wanted this so badly.

Was the doctor's office checking on your eligibility for the surgery? If so, they did drop the ball by not telling you about the clause and continuing with your testing and hoop jumping that is required. Why was the insurance company paying for testing out of a bariatric center if they don't cover this? Get your answers and make them accountable. This must feel surreal and devastating please don't give up and fight for yourself. I was a self pay and wished I could get the insurance coverage but was emphatically shut down immediately so I don't understand why all of this went on. Good luck!

[Wags 549]

I read the letter. Where does it say there is an exclusion? To me it reads that they need documentation of all of the things listed there.

Did I miss the exclusion part?

[SassyTink 78]

Wags, the first I heard of the exclusion was today on the phone. I called to find out if my paperwork had been submitted by the Dr's office. My last appointment was October 23 so I was trying to get that surgery date. I have called the Bariatric Center twice today and they have not called back. Somebody has to explain to me what happened. The Bariatric Center should have verified my policy 6 months ago. I can't get the approval for surgery it has to come from the Provider.

I can't stop crying. I have to get my hip replaced and can't get it replaced until I lose this weight. The hip pain is excruciating, and now mentally I am destroyed.

[Seela 1,187]

There has to be some mistake. I have the same ins but in ca. They deni me the first time too. I have faith that if you keep after it will happen.

[Seela 1,187]

There has to be some mistake. I have the same ins but in ca. They deni me the first time too. I have faith that if you keep after it will happen.

Btw.. I am only two weeks out so this was recent. If I had given up I would be sitting here today eating ice cream and stacy's chips! You know there is something wrong somewhere... a little detective work please Watson...

[Wags 549]

Wags' date=' the first I heard of the exclusion was today on the phone. I called to find out if my paperwork had been submitted by the Dr's office. My last appointment was October 23 so I was trying to get that surgery date. I have called the Bariatric Center twice today and they have not called back. Somebody has to explain to me what happened. The Bariatric Center should have verified my policy 6 months ago. I can't get the approval for surgery it has to come from the Provider. I can't stop crying. I have to get my hip replaced and can't get it replaced until I lose this weight. The hip pain is excruciating, and now mentally I am destroyed.[/quote']

Can you ask the doctors office to tell you why they had you go through all the steps without verification? That sounds crazy!

[LittleLinda 9]

I have BC/BS of IL also. I was told from the beginning that anything weight-loss related is a specific exclusion on my policy. I went to one clinic to get advice and information because I figured I might just self-pay if it was within a reasonable range. They asked to let them check my insurance anyway, even though I stated from the beginning I wasn't covered. They came back and told me I was covered. I was excited at first, but I asked them to re-check. They then came back telling me I wasn't covered.

The good news: I went to Tijuana and self-payed at a much lower cost.