Peer to Peer Update. DENIED 4th time

This must be one sick joke at this point.  So I got to work today and got a voicemail from someone in the Medical review dept telling me that the number I called isn't for me to call and its only for Dr to do peer to peer.  Now I called this number when my Dr told me no one called to have the peer to peer like they were suppose to at the set time given to them.  I found it ironic that someone gave me a call back for calling the number provided on the Denial letter but no one took the time to call my Dr back.  hmmm.  After speaking to my HR dept I spoke to someone who would refer my case to the Health care advocate.  When I got back from lunch today I got another voicemail from the Advocate that was assigned to my case.  I explain to her my entire situation and she sent me some forms to fill out releasing her permision to contact the insurance company and speak to someone.  She called me back an hour later and told me that somone call my Dr and left a personal number to call back and have the peer to peer.  She told me to still send her all my info just in case because she does not understand why they would deny me if I have all the qualification for the revsion to DS.  Before I left work I sent her all the paper work and I sent Dr Roslin all of the info I sent to BCBS of IL showing proof I was compliant again just to have.  I wanted to make sure he had everything he needed to give them a good fight.  I left work and took my train ride home and when I got out of the train station I got and email from Dr Roslin telling me he spoke to the Dr and that we will have to do an outside appeal.  He said that the woman was very prejudice against obesity and that he wants to speak to the health care advocate himself.  At this point I have to do a full appeal. (SMH)  Im wondering when should I contact obesitylaw.com or the state dept of insurance.  Should I contact these people after I send an appeal and get a denial or should I be contacting them for help now?

Iam so sorry you are going through all of this.   I think BCBS hires insane people to take care of
this dept.   I pray that you find out better news very soon!!

CindyLyn tell me about it.  I dont even have the energy to be mad or upset at this point.  Its actually becoming very comical to me. 

Hi there:

I see you went from the lap band to the sleeve. Did BCBS cover that revision? I'm in the process of getting all my paperwork sent in with the dr. letter, but my policy does cover bariatric surgery, but says the "sleeve" is investigative...I'm wondering if this surgery is even going to be possible for me. I really don't want the RNY, but at this point, I'm willing to do anything it takes. Any suggestions or help would be greatly appreciated. Thanks.....How are you doing with the revision? I had the band in 2004, lost about 30lbs and that was all...gained that back now plus some.....Bands gota go!! Thanks

Have you tried contacting http://www.obesityaction.org/home/index.php maybe they will know how to help you appeal.  they were at the OH event and i have the stuff to read but I haven't had the chance to read.

Sorry about your 4th denial ... grrrr asshats!

denials stink, what is the reason for the denial?  and adverse determination has to have a reason.   I will tell you unless you get a firm understanding of your specific adhesion contract they have you cornered.  without knowing this you are right where the insurance co wants you, ignorant to defend your position.    Dr Roslin is an insurance shark, but I will tell you he doesn't know your specific contract, and NO DR will take that time,  you have to be very proactive here, you need to get your contract and read it and understand it, especially when it comes to time lines, # of appeals and your right, this is not your benefits summary, this will have very detailed information on what/who to contact etc. and to make sure they are following the contract, oh ya they don't many times, question of peer to peer is somethig that insurance co have to keep detailed records about, when they tried to contact the surgeon etc, you have to get this info, I am amazed and shocked that I am the only person I know htat has a copy of my BCBS adhesion contract and I have read it and know it very well.   you also need to know your appeals process to your specific state, to know when you should contact dept of insurance regulation or an attorney because none of that will help if you run out of time or if you exhaust your # of appeals, and no attorney including obesitylaw.com will take your case without your adhesion contract so you need it anyway (if an attorney takes a case without this run for the hills-red flag)  ---um you can forget about your advocate, because they do not know you contract as it is specific to you.....arm yourself with information, and get informed .if you are not careful you will exhaust all your appeals, and/or time limits and no attorney can help you then.....

Hi Airbender

Im a little lost when you say adhesion contract.  What exactly is this?  Are you talking about my insurance policy or something else?  Reason given was lack of necessity and no proof of diet and exercise, variation of calorie intake.  I am assuming the denial for the peer to peer with be the same.  I will not find out until I call this morning for a copy of the letter again.  If you are speaking about my insurance policy for WLS requirement I know it like the back of my head.  Who exactly would I request this contract from?  This is the first time im hearing about this.

Hello

I just did a search on more infor on adhesion contract and it seem like your the only one on OH that talks about this contract. lol When I get to work I will be making some calls to see if I can get a copy of this contract.  As far as appeal process I have not yet gone through an appeal.  These denials are all first time process.  I have two choices as I was told yesterday.  To submit more info proving diet and exercise or do a external appeal.  With the help of Daiana Cox and Laura they feel its time for an appeal but I will look into this contract I see you speak so much about.  You have me very curious now. 

sorry for the consufusion, your subscriber agreement, not summary of benefits, you should get it from your HR dept.  but do not let them give you the summary of benefits,if they cant get it to you, call the insurance co, be leary if they say oh i can help you with that, you want to read it cover to cover,   in there it states your rights to appeal, the steps, who to contact, how long you have, how many levels you have etc.  to preserve your time lines.  it also must clearly and plainly spell out your exclusions etc.  also every state has rules for adverse determinations, dept of health, dept of insurance reg. , etc  depending on who governs what they can also help.  it seems you have some great people helping you....denials stink, but don't let them get away with it, exhaust all your appeals, keep fighting till you get your ds, Dr Roslin will help also....I wish you all the luck with your insurance co, just don't give up.......

Airbender you are so right.  This PDF I received from my benefits person has all the information you just ment.  I found out my job is indeed self pay and I have a 180 from date of denial.  It give me all the steps I can take for appeal.  It is so informortive the I can not believe it.  The health care advocate is actually very helpful.  She is getting through a lot of red tape to my surprise.  She told me to hold off from sending my appeal until she speaks to the medical board herself on Monday.  She reviewed all of my paper work and do not understand how I do not meet the requirement for surgery.  She have a appt with them and will be going over ALL of my paper work with them on moday.  So now I wait gain. 

I will not give up.