sharriad
I like to read, swim, go to amusement parks, etc. I like cruises...but best of all i like to feel good....can't wait for surgery time.
09/20/06 - I just submitted all of my paperwork to the surgeon. I got a call today that all was in order and that all of the p/w was there with good documentation. She said everything looked good and she was submiting it to insurance today. So now I will play the waiting game with my ins co. Cross your fingers. I am hoping they will not be too difficult. I checked with them prior and know that there are no exclusions by my employer for this surgery. I think our employers policy is pretty lenient, but not sure. I know they did just change their policy from 12 months consecutive monitoring with your doctor for supervised weight loss attempts...to just 6 months attempts within the previous 24 month period. I will keep you posted.
09/22 - I talked to the insurance company today...they rec'd my p/w - it will go for review. cross your fingers.....
09/26 - WEll i called BCBS of IL today for status...they said it was not approved as they need add'l info. I asked what add'tl info..and they could not tell me...but faxed the letter to me. I then made him read it to me over the phone...and it was there whole policy he was reading that they needed. I said...we already sent everything your policy requests..ALONG with a copy of your policy. He did not have an answer. Sooooo my surgeons office is calling tomorrow to speak w/management to find out what is going on...as it was all there. My surgeons office was so confused as there was great documentation provided. So I am kind of bummed....any words of advice?? I am needing it.
Tracy
10/03/06 I submitted my paperwork to insurance and QUICKLY got a letter stating they needed additional info. My surgeons office sent them a not so nice letter along w/another copy of their med policy stating all the info was there and she highlighted, circled and arrowed the info and re-faxed.
I just called again (as I have been every morning since she re-faxed it) and everymorning I usually get the "it is sill in review" quote.
This morning the gilr said it has went to the next step to the doctor to review and that it was a good thing. She said it is not definite yet..but usually a nurse reveiewer reviews it first and if it does not meet the criteria or needs add'tl info ..the nurse reviewer sends the denial letter. She said if everything is in line then it goes on to the dr. for final decision. But the dr. has to make the final decision.
(plus just found out yesterday starting 01/01/07 that my company will have an exclusion for WLS. BUT if you already have you p/w in before then they will honor it).
Tracy M.
10/05/06....still waiting. called again this morning and was told they should have a decision tomorrow. ( I was wondering how in the world they know the decision will be in tomorrow??)
10/06/06 - Well the did not lie...they certainly did have a decision right at 8:00 am when I called for status - ......yep you guessed it... DENIED!!! I am so very irrated. I have done EVERYTHING they ask....and for what?? them to give me a hard time. She asked me if I wanted her to start the appeal process.....I told her not until she hears from my attorney...along with a Dept of Insurance complaint. UGH! I am so irriated...i left work early today...i am starting on my packet to send the attorney today.
10/09/06 ....spoke w/my surgeons office and faxed the denial letter I received. My surgeons office is wonderful by the way...they really go above and beyond. They faxed additional info showing my exercise attempts and my nutrional therapy certificate. WE will see.
10/10/06.....I called BCBS of IL this morning...even though they are being a pain in my big toe....the customer service is great. I have been talking to one girl in particular and she really has gone out of her way to help me. She said they received the additional info from my surgeon and it will go to be re-reviewd. I also threw in some additional info that she typed up. Then if it is denied again it will just go straight to appeals...i will not need to send a letter or call back - as so took all the info over the phone as to why I am appealing if they do not approve it this time. I explained to her that I am in the insurance field and am familar w/contractual duties. That I pay my premiums and expect to get service for what I pay for....I explained that I have met ALL their criteria and then some. I listed all their criteria and how it was met. She said she thinks they were looking for counseling on exercise. I told her to put this in my appeal...but no where on their policy does it say I have to list step by step every minute what I have done for exercise..but that my doctor and I did discuss it frequently and that I exercise 3-4 times a week. I explained sometimes I go to the gym and walk on the treadmill for at least 30 mins and do some light weights...but can't do longer than that due to back & hip problems. And I expld if I don't make it to the gym...then I walk in my neighborhood for 25-30 mins. I futher explained as far as counseling for excercise..that being a member of weight watchers and going to the meetings emcompasses all of that & my provider and I discussed that was well.... I told her to put this in her notes that every meeting at weight watchers is about a different subject..counseling on exercise...lifestyle changes, .....eating habits...behavior modifcation and why we eat when we do. I expld all this criteria is met thru the weight watcher meetings. I expld My BMI has been over 40 w/co-morbidities for over 5 years. I have met everything they ask and I expect them to adhere to their contract. She is going to forward it on...so we will wait again and see.....I will wait 2 weeks and call for status. I told her to make sure she tells them in my letter that I am NOT going away.
10/12/06 - You know every day I call them it gets more interesting. I get my EOB's on line..and last night was looking at an EOB and saw there was a place to send msgs to BCBS of IL..so I fired off a letter that said this:
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Please advise me status of my pre-approval for gastric RNY surgery. The additional info from my surgeon's office has been faxed on 10/09/06. I have met my duties by paying my premiums and meeting ALL your criteria you requested for this surgery, as well as using a PPO provider that is on your list that you work with....EVEN though it is a 2 hour drive for me. I have met my end and expect that you do the same by abiding by your contractual duties and approving this surgery that is medically necessary. I am in the insurance field and am familar w/contractual duties and the responsibility that you have to uphold them. AS per my paperwork submitted you will see I have met the 5 years history, MORE than 6 months of supervised diet w/my PCP & weight watchers, my psych eval, the nutrition class, I am well over 18 and my BMI is at 50 and has been over 40 w/co morbidities for over the last 5 years. Thru weight watchers I also received counseling for excercise..that being a member of weight watchers and going to the meetings emcompasses all of your criteria on what the weight loss program component should consist of:
every meeting at weight watchers is about a different subject.. counseling on exercise...lifestyle changes, .....eating habits... behavior modifcation and why we eat when we do. This meets your criteria of: A program will be considered appropriate if it includes the following components:
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.
Behavior modification or behavioral health interventions.
Counseling and instruction on exercise and increased physical activity.
Pharmacologic therapy (as appropriate).
Ongoing support for lifestyle changes to make and maintain appropriate choices that will reduce health risk factors and improve overall health.
** I have met everything us ask and I expect you to adhere to your contract. AND just so you know.. I am NOT going to just go away. I have rights and will enforce them accordingly.
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the response I got was this:
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Dear Ms. Mixon:
Thank you for the opportunity to assist you with your recent inquiry regarding eligibility of benefits for gastric bypass surgery.
We carefully considered your request but found that gastric bypass surgery would not be eligible under your health care plan because the patient gained weight on the supervised weight plan. Unfortunately, our reply could not be more favorable.
The documentation submitted has been forwarded to our appeal department and you will be notified of the outcome in 30-45 days.
If you have any further questions or concerns, please contact the Customer Service Department at 1-888-652-4013 between the hours of 7 a.m. and 7 p.m. Central Standard Time or via Blue Access at http://www.bcbsil.com/statefarm/.
Sincerely,
Jennifer B.
Blue Cross Blue Shield of Illinois
Customer Service Center
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I replied with this...(the are forwarding it to the appeal dept******************
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Thank you for your response. I will await the appeal process. In your policy it says nothing about successful weight loss has to be the result before approval- it simply says that "It is expected that appropriate non-surgical treatment should have been attempted ".....which it was. The weight gain was not as a result of my diet - but if you read my notes..it is from severe edema which I was put on Lasix & a potassium pill to control the EDEMA. Your policy reads as follows:
"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.] ". I would like this info and this letter to be forwarded with my appeal. And a response received.
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Have you ever heard of this??? Can they deny it because I have gained 10 lbs from edema??
I called my benefits dept today in our corporate office and complained. She told me that once I get the first denial...then it goes to BCBS appeals dept...if THEY deny it .then I can send it to our benefits TOTAL REWARDs appeal dept for the final decision...and the final decision is theirs ..as they are the ones who writes the policy....
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12/22/2006 >>>>>> FINALLY I AM APPROVED. I HAVE BEEN WAITING ALL YEAR TO SAY THIS. AFTER MUCH EFFORTS...THEY FINALLY PAID OFF. MY SURGERY IS NEXT WEEK ALREADY......
EVERYONE PLEASE PRAY FOR ME.......
