Question about BCBS IL......

kleiweke · January 23, 2008

I have a BMI of 42. I was told and recieved a copy of their benfits as followed please tell me if I am wrong but I should be fine for insurance approval based on my BMI and I have tried several different weight loss programs.

Thanks,

Kelly ( ST. LOUIS)

Coverage:

The following criteria and guidelines have been developed to judge eligibility for coverage of bariatric surgery for the treatment of morbid obesity.

To be considered eligible for benefit coverage of bariatric surgery for treatment of morbid obesity, the following three criteria must be met:

A diagnosis of Morbid Obesity, defined as:
1. Body Mass Index (BMI) of greater than or equal to 40 kg/meter squared; OR
2. BMI greater than or equal to 35kg/meters squared with at least two (2) of the following co-morbid conditions which have not responded to maximum medical management and which are generally expected to be reversed or improved by bariatric treatment:
  - Hypertension,
  - Dyslipidemia,
  - Diabetes Mellitus,
  - Coronary heart disease, and/or
  - sleep apnea.

At least a five-year history of Morbid Obesity supported by medical record documentation.

AND

It is expected that appropriate non-surgical treatment should have been attempted prior to surgical treatment of obesity

Non-surgical treatment of morbid obesity appropriateness criteria:

Medical record documentation of active participation in a clinically-supervised, non-surgical program of weight reduction for at least 6 months, occurring within the twenty-four (24) months prior to the proposed surgery and preferably unaffiliated with the bariatric surgery program. [NOTE: The initial BMI at the beginning of a weight reduction program will be the “qualifying” BMI used to meet the BMI criteria for the definition of morbid obesity used in this policy.]
A program will be considered appropriate if it includes the following components:
1. Nutritional therapy, which may include medical nutrition therapy such as a very low calorie diet such as MediFast or Optifast OR a recognized commercial diet-based weight loss program such as Weight Watchers, Jenny Craig, etc. (TRIED BOTH)
2. Behavior modification or behavioral health interventions.
3. Counseling and instruction on exercise and increased physical activity.
4. Pharmacologic therapy (as appropriate).
5. Ongoing support for lifestyle changes to make and maintain appropriate choices that will reduce health risk factors and improve overall health.

KaitlynsMommy48 · February 9, 2008

I also have BCBS of IL and I have been denied twice so far. My BMI is over 50 so you would think it wouldn't be difficult. I have been going to the doctor faithfully once a month for the past 6 months and have been put on a restrictive diet and exercise program. Everything has been sent to BCBSIL and they have still denied me. They come back each time saying the doctors records aren't "specific" enough. I would like to say that my doctors office is AWESOME!!! They have faxed over mountains of ppwk to the insurance company and they are doing all the work for me. THe only thing I had to do was keep a 6 month food journal because BCBSIL required that. I am actually scheduled for surgery this Wednesday and am on the liquid diet right now. The review board told my docs office they should have an answer on Monday with the decision. I could possibly be doing this liquid diet for nothing but I sure hope not! I'll let you know what happens. My docs office said that this is the first time she has dealt with BCBSIL and it is the worst company she has had to work with. She said if I get denied a 3rd time we will involve lawyers which will not cost me anything because they work for my surgeons office and anyone in the program is able to use the lawyers. I hope we do not have to go that route but I will do whatever it takes.

Good Luck!

Alison

Scheduled banding 2-13-08

harleys mom · February 10, 2008

Could you tell me where in Illinois you are at and where you are having your banding done? I am in central illinois and looking into the two programs in Peoria (osf and methodist)