Denied by BCN Premier Care - 1.5 wks before surgery!!!

This is my first post.  I've been on this journey for almost 2 years.  I had a surgery date (11/17), went through all my pre-op appointments and then my insurance company denied me yesterday.  They said my medical records did not EXPLICITY say that I FAILED non-surgical management attempts, including a professionally supervised diet.  Well I had seen my doctor for OVER 13 FREAKING CONSECUTIVE months, NEVER missed an appointment.  He documented everything....I can't believe this.  Everyone told me there should be no problem that I had more than enough documentation.  I'm hoping that the program doctors will call to find out exactly what they are looking for.  This is ridiculous.  I am so uttlery disappointed and extremely depressed right now.  Does anyone have BCN Premier Care through Univ of Mich?  Has anyone else experienced this?  Any sugestions?    

Update - the 'detail' that was 'missing' was that my doctor in my file said that 'we discussed diet changes'... but because he didn't EXPLICITY WHAT those recommended changes were I was denied.  Can you BELIEVE THAT?  I'm so mad.  I have to file a grievence...well to do that I have to wait for BCN to send me the package.  Hope I get that sometime this year!!!!!!!!!! If there is anyone that has had a similair experience I would greatly appreaciate any suggestions for what to include in my grievene package.  Thanks for listenting.

I'm SO sorry this happened to you!!  I have UM/BCN Premier Care too and am terrified that they'll deny me (am planning for surgery in early January).  Did you have that form that UM Bariatrics is giving to PCP's to fill out?  DId Pam give you any sense of whether they can help get the decision changed?  Good luck and keep up up to date on the appeal.  Stay tough!!


lara

I've been in the program for awhile so, the forms that Pam gave out were after I did all of my time so to speak.  But everything that's on the form my doctor and I covered.  He just didn't list the explicit diet changes we discussed.  I have notes from my meetings with him, so I'm going to go back and put together a letter with that information.  I've also got an appt with PCP on Tuesday to discuss all this.  The admin said that they would help, but it's in my hands.  I have to file to the grievence.  Good luck to you!

That's terrible - I hope they'll take your letter and approve your appeal.  Did they think that it was possible you'll be approved to keep your original surgery date?

nope won't be having surgery in November.  I asked if anyone else in the program had been denied for similair reasons.  There was someone and they rececently had surgery, so I'm hoping to find out what they submitted that got them approved.  Either way I'll have to wait until next week or the following to get the papers from the insurance co, then I'll have to follow up with the docs to the additional documentation.  I don't see me having the surgery this year.  Which is concerning cause I wonder if there are changes that will start on 1/1 when our benefits start over.  I'm getting more depressed as the day goes on.  I did so much work before even going to the program.

File for an expedited appeal being that you already have surgery scheduled.  They might not consider it, but you do not know if you do not ask.  

First off..Who said you "should be OK?" Was it your Dr? his nurses? Uof M? or people from this board or just friends? You need to step back...take a deep breath ...we did not need this surgery because we gained weight over night....BCN are the only people you should be asking questions too..take names and numbers....you really have to cover your ass when you talk to anyone. Do you know how much this surgery cost? try around 60,00 to 70,000.00 no one will OK a surgery like this unless you show you have tried. I am sorry for everything your going through but you have to cover yourself...

If for some reason you have to start the process over...get a new Dr...find out what your Dr really knows about  this surgery ....f they are Well not a whole lot" you need another! I went from the Lap band to the RNY and had to prove 4 years of diets...go figure~

Maria
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What does your surgeon's office have to say about this?  WLS is a lifesaver for us but it is a business for them.  I can't imagine that they would let it go this long without confirming that they will be paid.  They have to reserve an operating room, a patient room, assistants in the OR, anethesiologist, and they have to do this in advance. 

Have they told you that you will have to self pay?  Have they told you they are handling it? 

Michigan Bariatric Institute had insurance approval in writing before any other steps were taken.  I can't imagine any other way to do it.

Best wishes on this journey, I hope your surgeon's office is more organized than they appear from your post.

I had a similar problem with trying to get approved the first time with Cigna HAP PPO.  I did find out after going through all of my appeals/grievances that the PCP cannot change any records once they are recorded, but they can amend the record to reflect more accurate information.  Talk to your PCP to see if they can amend your records so the verbiage is more clear.  Good luck to you.