Relatively new poster here - Need your help!

Hi all, I have only been coming to the NC boards for a few weeks now, but I've met some wonderful folks already.  I mostly post on the DS board because that is the procedure I am pursuing, but I have been trying to get here and read more about my own local folks. Thing is I need some advice.  Here is the link to the post since it is a lengthy one and I'd rather not have to get all that down again (and I probably would leave something important out):  http://www.obesityhelp.com/forums/ds/a,messageboard/action,r eplies/board_id,5357/cat_id,4957/topic_id,3628265/. I realized that even though a lot of you all might have had a different surgery type, it's still possible that some of you had to fight hard for your surgery of choice.  I'd REALLY appreciate any advice anyone has, especially if you had to go through an appeals process here in NC. Thanks so much in advance and have a great day!

First off, calm down.  Be pissed off all to hell, but calm down.  Pissed off and calm is a leathal combo, IMHO. I don't have any words of advice in terms of appeals.  I'd call your surgeon first thing tomorrow (duh!) and then call the insurance company directly.  Find out any other hoops you might have to jump though. The curiosity I have is this: would they be as reticent to give you RNY or is it just a WLS-bias in general?  I know alot insurance don't specifically cover DS because they deem it too experimental (WTF ever), but I don't know if your insurance is that far in the stone age or not. I *will* be at Perkins afterall.. so I'll let you commiserate (i.e. ***** and moan) to me all you want.

Thanks, Hon.   Yeah, I needed to B&M today and curse like a sailor till I got it all out.  But now I am calm and pissed off.  I'm so glad I didn't get this in the middle of the week while at work - last time I got a phone call on a Friday but thank God I was standing in the Boston airport and not in cubeland back at work where every whisper is heard.

I have at least decided to call Dr. Smith's office, and then I'm also calling the NCDOI.  On some good advice from Diana Cox, I went to the DOI website and found out that if you aren't represented by an attorney yet, they can advise you on how to proceed through the internal appeal process within the insurance co.  I'll call them, too, and make nice-nice to ask for all the documentation I can get my ahnds on.  Because knowledge is power and if I know what they want and need, I can better stay one step ahead.  Thing I'm concerned about is that they keep moving the target.   About the RNY vs. DS, I don't know that answer to that.  I do wonder.  My policy specifically says it will cover all types and is pretty inclusive - at least it seemed so when I read it.  I called also and they said as much then as well.  Who knows??    They may be as reticent about all WLS even though they claim to cover.  I think at this point, they keep changing the requirements to meet the criteria for medical necessity.  And seriously, if all they can come up with is that the surgeon didn't send results of a physical exam, I'd say they're scrambling for poor excuses at this point.  I hope they screw up and break the law, because the minute they do, I'll have them by the balls. I'm kinda crazy like that.....

I'll see you at the meeting then - thanks for reminding me to RSVP!

Hi Angela, I'm sorry to hear of your problems with NC BCBS.  I'm not exactly a fan of them right now myself, because my first choice of surgery is a Vertical Sleeve Gastrectomy, which, of course, our wonderful  NC  BCBS does NOT cover!! I'm not sure  which plan  you belong to, but looking at their general obesity surgery policy that they have online, I see where it says that coverage for the DS will be on an individual basis.  Since I haven't really seen anyone on here have a problem getting BCBS to approve their RNY or LapBand (having met all the requirements YOU already seem to have done!), I can't help but wonder if it's the DS that's making them so difficult to deal with.  I really don't know, I'm just trying to help figure out what game they're playing with you!! Another possibility that occurred to me was the fact that I see you are in Durham and are covered by NC BCBS, yet your surgeon is in Georgia.  I wonder if that has anything to do with it? Maybe they really only want to deal with in-state surgeons??  Once again, I don't know. Good luck with your phone calls tomorrow, and  I hope you get some answers.  Please come back and let us know what happens and what you are told.  I'm sure I speak for everyone on this board when I say we are all pulling for you to prevail over "The System"!! -Cathy W.

Hi Angela,

I can feel your frustration. I'm so sorry you are going through this. I'm wondering if it might not be a 'clerical' error on there part? When you talk to the Dr's office, I'd ask if you can get a copy of what they submitted? Do you have the physical exam by the surgeon? If so, I'd ask them to please review the information submitted so that you don't have to go through an official 'appeal' process.

I don't know if you have cross-posted this to the "Insurance" and "Main" forums, but you might get some more 'info' there.

I look forward to seeing you later this month.

Barb

Contact the NCDOI - department of insurance... they can assist you with the insurance company or at least let you know of your options and other resources.

Angela, You have earned a Big Gold Star from me because I see you are very determined to see this through. It took me three years to get a surgery date. The reason why is I changed surgeons and happy I did . Needless to say I had to stay on top of it all. If you dont have a fax I would fine one you could use or buy one. Make sure you have copies of all the test you have had and make copies of all insurance letters you get. I had to appeal to my insurance. I wrote a letter basically explaining what life was like for me as a super morbid obese person. I hand delivered my letter to BCBS. I will never forget that day at that time I still had to use a cane when walking. Angela you keep fighting and do not stop!!!! Make phone calls everyday if you have to till you get answers. Keep copies of everything. I will be at the meetup on the 21st and it will be great to meet you.                                       Annie

From what you posted, it appears the only thing they are missing is your surgeon's physical exam of you and his recommendation of the surgery.   If that is the case, it should be easy enough to fix.  I would call the insurance company and ask them if this interpretation is correct. Take care and good luck, Pam

Thanks you all!  I have taken in all the great suggestions from everyone, and I am happy to report that I have contacted the NCDOI and I am going to fight!!  Yes, it does sound like all I need is an exam by the surgeon, and we'll be scheduling that ASAP.  The NCDOI folks are great!!  And I REALLY appreciate all your well-wishes.  I saw a great sign today that brought it all home to me, and I'm going to remember and do this everyday even sometimes when it's hard.  It said, "Why worry when you can pray."  So I ask you all to keep praying anf swinging some chickens, or do whatever it is you do.  I surely appreciate it! I'll keep y'all posted - I'm going to fight the evil empire!