Just one more step for my appeal...

Three4Me
on 1/29/09 11:48 am, edited 1/29/09 11:54 am

I am really getting excited....I submitted my claim back in September 2008& was denied---however, w/the denial they said that I have completed all that is required of me w/my BCBS of PA insurance EXCEPT for the six month physician supervised NUT & xrcise requirement. I had a July 2007 appointment w/my PCP and a September 2008 appointment w/my PCP that I submitted & they acknowledged (in case your wondering, I'm not a total idiot---I know that is not six months worth of appointments......the way my policy is worded, it says six months "cumulative", not consecutive, so Dr. Houston's office had me submit it because there were 6 months inbetween appointments and I had continued with the dietitian & personal trainer. Well, that didn't work & BCBS denied me.

Luckily, I have 180 days for the initial appeal from the date of the denial. Of course, that's 6 months, so, since I already had two appointments, I figured that if I got at least five more appointments in (the first one doesn't count as a month since it is when you begin, I was told) w/in the 180 days then I would submit the additional Medical Documentation Forms w/in the 180 days w/my appeal & be approved. So, that's my plan!!!

I have spent the last week making seven complete packets for the appeal. Each one is dated the day of my PCP appointment and includes a copy of all the documentation from the registered dietition at Centennial and from my personal trainer at the Y--it also includes my medical records showing that I met w/my PCP and he supervised my progress w/the dietitian & trainer. I made sure each packet has everything required in it, including all medical records and signatures from my PCP, dietition & personal trainer so that the insurance company can see that I have done what is required. So, they will get July 2007, September 2008, October 2008, November 2008, December '08, January '09 and....

MY VERY LAST APPOINTMENT IS ON FEBRUARY 3RD!!! I meet w/Pam, the Dietitian on Monday morning & my personal trainer for a final Microfit Evaluation on Monday afternoon & then Tuesday morning I have my LAST appointment with my PCP. He is SO VERY SUPPORTIVE & so he will have a second letter confirming he supervised me for six months in my diet & exercise & then I will be Fed Ex'ing the packet to the appeals lady (who, by the way, detests me....she initially immediately appealed my first level denial and I rcv'd a second level denial by mail....I called her & told her that my policy states that I, the policy holder, initiate the appeal and that it is not her job to do so. She said that they automatically appeal denials. Nope. That wasn't going to work b/c I only have so many appeals before I run out of them. So, she was wrong & I told her (w/a smile of course). We went back & forth & I finally had to send her a copy of the Plan Summary & highlight where I have 180 days to appeal it & that I am the one who initiates it. So, she made the second level denial "null and void" and kept me at just one denial....but she wasn't very happy about it.....ug!).

At any rate, I am really, really just wrapping my head around all of this, so this post is probably WAY too long while I ramble, but I am just so excited. On the first level appeal they have 30 days to render a decision. Since the appeals lady loves me so much, HA!, I am sure she will take her 30 days...lol....but, at the latest, I should have a decision by March 6th! And, hopefully, schedule my surgery for March 2009!!

Wow, sometimes it really seems unreal that this may actually happen. I am so willing to fight for this....we waited until our 30s to have kids and, after fertility issues, were able to have three precious little ones in my 30s....since they are 6 years, 3 years &, with my youngest being 22 months, I just want to be around to see them grow up & have the energy to run around & play w/them!!! I just want them to have an active, healthy mommy. No supermodel goals here, just being able to keep up w/the little ones would be enough!

SO, keep your fingers crossed & say a prayer....wish me luck!! I'll keep you posted & try to make it shorter next time. By the way, if you actually hung in there & read this entire (long) post...THANKS!!! Micheala.