[Cherri]

Hello all, I finally got my denial letter in the mail. On the phone they said my Dr supervised 6 month diet was not a very low calorie diet and that was the reason I was denied. I went through a dietician affilliated with the surgeons office that they always use, so I know they know what they are doing. When I got the written denial, it states, lack of evidence of participation in a very low calorie diet, as evidenced by lack of significant weight lost. Thier requirements don't state any amount of weight to be lost. I have BCBSIL PPO, I can look up their requirements on their web, and also have it in writing, and it states that no where. How do I fight this other than doing the 6 months all over again? Any help would be appreciated, I am new to this appeal stuff, and noone has called me from the surgeons office yet about the denial. I know they have someone that works with them, but not sure on what to do. Right now I hate BCBSIL.

[Lch]

start with the Dietician and see if they can write a letter, and call the insurance and tell them you want to appeal the decision and find out what exactly they want. That's what i would do. The first time i was denied, i was denied twice... i hooked up with this middle man of sorts through our carrier, and he made all the calls, etc.. but the second time, i got involved too, and made lots of calls, got lots of backup.. the second time they said i hadn't met the dietician class requirements, i went to where i did it and they wrote a letter to the insurance... and it must have helped. Personally i believe the insurance companies do this just to see if you will give up. they denied my dad too, once, but he had his surgery 3 months ago, just keep at it. and good luck. don't get discouraged, i know that is easy to say, but harder to do, i cried many times. keep us posted. And i am sure there is someone on here who has gone through the same exact thing and will help guide you in the direction you need to go.

[DocSanae]

Rather than wait for the surgeon's office to call, I suggest you call them first. You may have to do the diet they require, I know it's frustrating for you, but often, taking the roundabout route is the fastest way. After all, if they denied on the grounds that you haven't done the 6 months diet, and no other reason, if you do as requested, then they have no reason to deny you after that. 6 months may seem long, but compared to a lifetime, it will have gone by in a flash when you look back.
(((((HUGS)))))

[Cherri]

Doc, that is the thing I already did the 6 month diet through the dietician that is affiliated with the surgeons office. So I know she would know what calories the insurance is looking for. She put me on 1200 calories, what the insurance is saying is because I did not lose enough weight on the 6 month diet, that I need to do it over again. Except it is no where in their requirements that you need to lose a certain amount of wieght. That is why I am so angry with them right now. I jumped their hoops got them everything they asked for and then some. Then they pulled this last trick out of their hat. I just don't know how to go about appealing this, other than starting all over again. However I don't believe they will give me any lower of a calorie diet. I lost 5 pounds total according to them. I know of people who gain and get approved I just don't get it.

[DocSanae]

There's a type of diet called very low calorie diet that is under 1000 kcals. That may be what they are talking about.
Usually, 1200 kcals is the low end with diets, but some patients are put on 800-1000 kcals very strictly regulated diet. That is probably the trick they pulled out of the hat. It may be the insurance co changed the rules and the nut didn't know--which seems to happen often enough, I don't know if the insurance cos are obligated to notify the changes, but I've run across some posts where it seems they neglect to notify the respective parties.

[mlg78]

800-1000 seems drastic unless you're preparing for surgery like gastric bypass. I'm no dietician, of course...but to put a patient on that low of a diet seems crazy. 1200 seems much more sufficient.

[Trulykath]

Not sure about your surgeon's office, but mine has a coordinator who fights the insurance companies ALL THE TIME!!! I would get involved, but I would see what the surgeon's office can do to help also....they are used to this and usually VERY versed in what it takes to reverse a denial!

Hope you get this worked out!! Keep us posted!

[poochsgirl]

I have BCBSIL PPO too! I actually didn't think I'd be approved. I had to have a BMI of 42 according to my height, for them to accept me. My nurse told me this before I seen the doc the next week. She said not to lose any weight since I was right on the border. I freaked and ate and ate. I actually gained about 5 pounds and I was accepted. It's a good thing too, I think I was at a BMI of 41 when I seen the nurse. I had my surgery a little over 4 weeks ago. I'm not sure if my bill was paid yet, but they did approve me at 100% hospital coverage.

Even though I have the same insurance as you, it's actually through the Chicago Carpenters Welfare Fund for Union Employees. Even though our insurance is the same, some of the benefits vary due to the agreement between the union and the insurance company. I had to go through a behaviorial modification program through one of their mental health companies. I had to meet over the phone with a coach every week for an hour.

I have tons of experience with denials and insurance companies. (my son is handicapped and for 9 years I've fought with one insurance company or another to get my bills paid.) I would do 2 things. Call your insurance company and ask for a manager to talk to about your case and call your doctors office and have them work with your insurance company too.

Good luck to you and don't give up. I've met alot of folks that have had the same problem as you and I know most of them fought til they were blue in the face and a high percentage of them have had their surgery.