BCBSIL - Denied Again

DENIED AGAIN
"The request for the surgical treatment of morbid obesity is being denied as the following criteria listed below has not been met:
*It is expected that appropriate non-surgical treatment should have been attempted prior to the 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 twenty-four (24) months prior to the proposed surgery and preferably unaffiliated with the bariatric surgery program."
And then they went even further with this:
"A program will be considered appropriate if it includes the following components:
1.  Nutritional therapy, which may included 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 Weigh****chers, Jenny Craig, etc.
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."

I am so disappointed,  angry,  pissed off,  frustrated, and upset  !!!

BUT I refuse to accept their denial.  I absolutely need the surgery and the lifestyle changes, and the emotional support, and the physical transformation.  I cannot give up.  I began an appeal process yesterday with letters.  I'm assuming that the staff at Dr. Eibes' office will be doing the same, but I just feel like I need to speak up for myself.

First I wrote a letter to every WW location where I have joined over the past 10 years and asked that they forward every record of my joining and my weight records to BCBS and me.  I cc'd Dr. Eibes, my PCP, and BCBS on the request. 

Then, I sent a letter to my PCP w/a copy of the denial letter and asked that she send BCBS a letter (and a cc to me) providing detailed information regarding the activities that ensued during my 6-month supervised non-surgical program that I completed with her between October 3, 2008 and April 15, 2009 PLUS I asked that she provide her professional opinion as to whether or not I could benfit medically from having WLS.  I cc'd Dr. Eibes and BCBS on that request too.

Next, I am going to write a long and detailed letter to BCBS and I am going to advise them that their denial is not acceptable to me and all of the physical and emotional reasons why I need to have the surgery.

If anyone has any ideas or suggestions that might help me during the appeal process, PLEASE do not hesitate to share.  I need all of the help that I can get.  Also, your prayers would be greatly appreciated. 

Hi Kim,
I have bcbs of tx which uses the same exact medical policy and had no issues the first time around.  It almost sounds like your dr has not sent in all the medical records.  My situation may have been a little different but I had moved and I requested my own medical records and supplied them to the surgeon so I was totally aware of what they contained as well as asked my current dr what he was sending.  Did your dr notes on your 6 month diet have any detail to them or was there just a notation of your weight?  My surgeon had given me a form to have my pcp fill out so it was clear we had a discussion on my goals/progress in weight/nutrition/exercise on a monthly bases. Anyways that is where I would start, ask Dr Eibes office to see the package they submitted, ultimately they are the responsible party for ensuring they submit the correct data since they are the ones performing the service.  Keep trying..

Kim,

That really stinks!!  I am in the process of going through the 6-month physician supervised diet visits and what you have written has scared the hell out of me!  I am curious, did you loose much weight during that 6month period.  (I really haven't, and it has been 4 months, and I'm afraid because of that, that I will get denied.)  It really sounds like you have taken the right steps to appeal their denial.  So I see you wrote, 'denied again' is this your 2nd denial?  And do they keep denying you for the same reason?  Just curious.  I hope you can get everything to work out for you!  Keep us updated!

Kim,

First let me say how sorry I am that you were denied.  I know it must be so frustrating to get the denial letter.

I have BCBS insurance but it's the Iowa plan.  I was approved the first try so I am inclined to agree that your PCP must not have sent in specific documentaion so that the insurance company would approve it.  I don't know of any others who have been denied by BCBS.  Keep trying and advocating for yourself and consider getting a second medical opinion if you think that would help.  DON'T GIVE UP!!!  You will win eventually.................I really believe that.

Keep us posted on things, too.  We are here for you and we care.

Carol

I turned in copies of my WW books ...  but if you did a six month supervised with your PCP - it sounds like perhaps the PCP just didn't provide the appropriate documentation about those efforts.

Also consider any reciepts you might have to show what you've done (payments for WW,  doctor office visits,   gym memberships, etc.)      Some of those in the last year will be online if you paid by credit card, or your bank has an online banking to print your checks,   or stuff you turned in if you have a flex account, etc.      

I'm not great at keeping and organizing receipts - but I was impressed by what I could find through electronic record keeping. 

Jody  

 

UPDATE

I did complete and mail the letters that I mentioned in my original post on Monday.  In the letter to BCBS, I shared that I had discussed the lifestyle changes I was putting into place - including that I joined a gym and the better food choices I was making - during my visits with my PCP and that, though the scale didn't show it, I felt that we did make positive progress during those visits AND that they helped me to realize many things about myself AND to prepare all the more for WLS.  Then, when I got home on Monday, there was another letter from BCBS stating that specifically the medical records did not reflect that my PCP and I discussed and worked on lifestyle changes and an exercise plan.  IRONIC!

Anyway, I spoke with my PCP's nurse this morning and explained to her what the situation is and that I need for my PCP to send BCBS a detailed account of the visits over the 6 months, including what we discussed, plans we made, and goals we set.  I told her that my PCP should call me directly with any questions about this and, that if I don't hear from her, I will assume she is doing as I've requested. 

So, I know that the information BCBS is requiring can be provided, and I am hopeful that they will reconsider and (fingers crossed) give me approval soon!

Many thanks to all of you for your suggestions and support! 

It has meant a great deal to me!

One thing that might help and speed up the process is for YOU to write the letter about the changes you made and things you talk about with your PCP during your 6 month supervised diet.  Then make an appointment with your PCP , that guarantees you get to talk with him/her, and show her the letter and ask that she sign it, make a copy for your file, and take your copy and send it into your ins co yourself!  That way you know its done!!

Your regular Dr and your Bariatric Dr.  need to get on the same page.  When applying for my surgery they worked together.  Once the 6 months were done and all my other program documentation,  I included weigh****chers, spark people tracking, My journals and measurements.  The person submitting it should be doing a better job of writing that letter requesting service.  If they arent good at that I would worry about the rest of the follow thru.  You should have had a sleep study for apnea, extensive bloodwork to show any significant issues like cholesterol ect. 

I know your upset , and angry, but keep having faith if you want this badly enough it will come thru for you.  I have weighted 2 years myself and just got approved.  It will happen have faith.

Denise