BCBS of New Jersey

[mem123 0]

Niecey

OMG! I though I would go crazy with the seemingly endless changing rules! I know exactly what you mean. You do the diet - then they want more. You have the co-morbids - that's not enough. When I finally thought I had it they said I had to be on TWO blood pressure pills, not one! I thought BCBS would give me a stroke before the surgery!!! I am so sorry they put you through this - but they have to keep their money (our money we've paid for years) as long as possible!

[CHACHA 0]

My bmi is around 38-39 and i did all the pscy eval and co morbs, had knee replacement due to athiritus(sp) in knees and feet so being overweight sure isn't good. The only thing i am worried about is i only did a 4 month pre diet with a doctor. And i don't know if bcbs nj will except this or make me do 6 months over again or just 2 more months??

I wish these insurance companys would just realize they will save money in the long run if they would just approve these and let us be healthier.

[Niecey 0]

I started this last year, end of August. Amy in Dr Morton's said they would require a 6 month diet so I could start that to save time. Sept 2007 was my first 6 month visit. I didn't get a letter from BCBS til Nov 2007 so I was well underway. I turned it all in, end of March they said something was missing. Middle of April they finally received something. I did not get a denial until July 3, 2008. So 10 months to get denied and that was only because the HR department got involved. I have gone to my PCP again to get a letter to appeal and ask for a "fast" appeal decision. Doc told me insurance companies are denying unless you have comorbidities. I am borderline diabetic but that doesn't count I'm told. I'm still going to fight it. I'll let you know how it goes.

Niecey

[Jersey Boy 0]

I was Finally approved after the six month "supervised" weight loss period, and a length letter from my PCP stating that we have been working on weightloss and maintaining weightloss for 14 years "unsuccessfully" It took 1 week then i got on the schedule for surgery and will have my band doe on 7/29/08. I can't wait. I'm getting nervouse now, with jut over a week to go.

[Niecey 0]

Jersey Boy,

My doc wrote I have been unsuccessfully trying with her for the last 6 years and what diets I have been on. Did you have any other problems besides being overweight, like high blood pressure or diabetes? Good luck.

Niecey

[CHACHA 0]

Hey Nicey, I am kinda preparing myself for a deniel.But gonna keep on with the appeal. Let me know how yours go. In my insrance book it does not say anything about a 12 month diet, 6 month dr documented

[Niecey 0]

Well it's August 16th and guess what??? My approval letter came today in the mail from BCBS of NJ. OMG I cannot believe it. I am 2 weeks shy of it taking ONE year to get approved. A few things helped...one was having my DH's HR department staying on the insurance company and the other thing is when I sent the appeal letter I had then found out I was diabetic and my PCP started me on medication. I think the 2 things together made it happen. So I will hopefully get a date on Monday when I fax the letter to Dr. Morton's office. I am so incredible happy. Good Luck to everyone having to go through this. It was very discouraging at times.

Niecey

[CHACHA 0]

I am soo envious!!! Good for you!!! Keep me posted

My BMI is 39+ had knee replcement due to arthiritus high Cholestoral so amd hopeful I will get approved, should know by the end of the month. My only concern as I went to a diet DR who put me on diet pills and metforum for 5 months and had to stop taking the medication as it made me feel like crap!

So keep me posted!!

Lory

[Ruby124 0]

Wow! You guys are getting me nervous. I have BCBS of New Jersey PPO. I will be using the services of Dr. Daniel Davis. The insurance company has had my info since July 7th. I was put in for a pre-determination. I am not clear on what that means. The insurance company told me it could take up to 30 business days to find out about my approval. August 15 was 30 business days and still nothing. I have no idea how this is going to go.

I work with a 27 year old girl who was approved in ten days (back in February) and had gastric (which I heard is harder to get approved for) with the same exact insurance I do. I have no idea what is going on. I am getting very anxious. :mad2:

[CHACHA 0]

Yes 30 days, but that means 30 business days!!, Mine was sent 7/9 received 7-15! I call every Monday and let them know I am still waiting!! Good Luck!!

[CHACHA 0]

Nicey, Can you give me an idea on your appeal letter as I just wanna be ready and prepared, is there any form letters ,do I write one or the DR??? or both??

Thanks

[Niecey 0]

Here is my letter:

"To Whom It May Concern:

I am requesting a “fast” appeal or an “expedited review of my appeal”. In September of 2007, Dr. Morton and my PCP submitted a request for approval for Bariatric surgery. I have been denied and since that time my borderline diabetes has turned into full blown diabetes. I have currently been perscribed Metformin 1000 mg twice per day. My doctor and I feel this procedure is medically necessary. Enclosed is another letter from my PCP and the diet I have been following since September of 2007. My father died from diabetes with many complications including having both legs cut off and his fingers decaying. I do not want to live that life. Quoted from the American Diabetes Association: “Weight-loss surgery helps reduce the seriousness of all four of the diseases studied. Diabetes completely disappeared in 76.8% of the patients and was resolved or improved in 86%.” Enlight of the fact I have just become diabetic, this surgery would help me get off of medication and reduce, if not eliminate, the possibility of dying from diabetes. I do not know why an insurance company would deny a patient a chance to live a full and healthy life. Please reconsider this decision."

My doctor's letter was also included. In the process of this I also found the step-by-step procedures for BCBS. I saved it in a word document. Is there a way for me to send you an attachment? I'll try to PM it to you.

Denise

[Ruby124 0]

:thumbup: Holy crap! If they gave you a problem I'm toast!

[Niecey 0]

I will tell you I sent that letter when I was denied but I don't know exactly what got me the approval. Apparently the first time my PCP sent in the info the exact diet that I was following was not included, so I also included a week's worth of the diet I was doing for 6 months which was an 1800 calorie diet. They worded the denial "based on information submitted this has been determined as not medically necessary." Maybe if I have included that the first time I would have been approved. They also did the 30 day thing with me too. They said not all the info was there and so the lapband doc resubmitted the same info. What that did was give them another 30 days. It wasn't until my DH's HR person actually spoke with the rep that I got a real answer of what was missing. They may have still denied me until the diabetes came into play. I don't know what did it but if you are determined and willing to take spend the time it will happen. Good luck and keep in touch.

niecey

[Jaculin412 0]

Wow you guys are making me a little nervous too. I have BC/BS of NJ PPO. I went for my surgical consult back in July. Met with the surgeon, did the psych eval and met with the nutritionist. Started my 6 month monitored with my PCP in June with November being month 6. When I was done with the consult I was given a surgery date of November 24th. I have two tests to get done at the gastro docs, consult with them set up this month and I assume the tests done early next month. The staff at my surgeons office said once I finish my 6 months monitored with my PCP then all notes get copied along with a letter of necessity from her. All this goes to my surgeon and they will submit ALL info. I'm assuming they don't feel it will be a problem getting approved as my month 6 is early November and they scheduled surgery for 11/24. I figure they know what they are doing. I am overweight with a BMI of 46, high blood pressure and just minor aches and pains.