DENIED !!! NEED SUPPORT

Please...  i need some support. i am SO upset. Jumped through ALL the hoops. Did ALL the tests. Blue Cross CA denied autho or RNY. i was told BC was great at approving surgeries.  Even though i was only a 37 BMI at time of auth, i have many associated health problems and was told that BC would still approve me. I AM BESIDE MYSELF. i dont know what to do next. Dr Michael Williams was the one at BC that denied the RNY  as "medically unneccessary." i was told that was not going to happen. i am freaking out.  Some may tell me to go thru the appeals process. i cant. i have to get back to work and find a job. i have put my WHOLE LIFE ON HOLD for this surgery. i feel like ive gopne throigh all of this for nothing. Do you know what its like counting on this surgery for 3 months of your life? i was told NO PROBLEM. you'll be approved. i feel like i am in a nightmare. One more peice of the story.  Per the guy i talked to at Blue Cross CA Pre Auth, here are the noations in my account: 12/21-Dr Williams left message wiith my Dr (Cunneen) with a request for him to c/b Blue Cross by 3 pm the next day. 12/22-Dr Williams enters  at 4:15 PM that since there was no call back from my Dr., "we will deny the claim." 12/22/06-Patient failed to meet crtieria of procedure #43644. Not medically necessary. Is this **** up of my Dr's office? Was there some peice of info Dr Williams neeeded to approve me? Sure looks like he needed something. Can anybody give me any feedback here? i cant stop crying. i wantt his SO bad. Thank you for any help or insight, sg debbie

Debbie  I had Blue Cross  of Texas  when I worked for Concentra.. and they approved Rueyn-Y  for me 2yrs ago with out a problem  Unfortunately I could not set a surgery date as I was informed that I would be laid off.. From your information the Dr at Blue Cross wanted to talk to your Dr... I work for  Major Insurance company and  if an Insurance Medical DIrector requests a Peer to Peer and can not get intouch with the other Dr often the request will be denied.... The solution is to talk with your Dr explian the Insurance Dr needed to talk to him and because he did not they would not approve the surgery... ask your Dr to contact the insurance company and request to speak to the Dr who did the review.... that might get Blue cross to reconsider the decision.... Otherwise you can  still appeal the decision WHen you talk to your Dr about this Have the Phone #  he will need to call and the name of the Dr who did the review handy Good luck if you have any questions feel free to contact me

Do you know if you can appeal to the State of California for an independant external review?  That would be your next step if you have that option.  You can also see if your surgeon will do a peer review.

Insurance companies are required by federal law to respond to an auth request within a certain time frame. They get audited all of the time.  So, if they couldn't get the info they wanted, ie talking to your doctor, then they deny the auth.....just so the request isn't sitting around.  If the request gets lost in the shuffle, and gets too old without official response, then it will cause them to fail an audit.   This was an administrative, paperwork type thing not a final answer, you get to try again.  Ditto on the other posts, get the Doc to call the insurance company back, they will re-open the request and you'll be in the running again.   Keep your chin up.

Debbie, first of all,,, read my profile. You will see it took me 13 months(as opposed to your 3) to get approved for this thing. You wont want to hear this, but in THIS journey,, 3 months aint NOTHING! Youre not done though. I would like to suggest legal follow up. Truth of the matter is, BCBS will deny you. Then, they will deny you again. They want you to go away. They hope you get all flustered, get overwhelmed, and GO AWAY.  I remember being told this when they were denying me also. And it all sounds cliche-ish,,, but you gonna have to exhert more effort in this. Know this also, they DONT wanna pay for these surgeries. Dont let this board mislead you into thinking all these stories end up happy,,, because they dont. People get denied this surgery all day, everyday. But at least go out with a fight. Thats the best advice I can give you. Steve Que

Steve I am sorry your approval too over a year ..... BCBS approved me in less than 2 weeks   Getting a lawyer involved at this stage is a bit  premature in my opinion  and could only serve to cause  even more delays...as well as add another expense... Most lawyers these days do not work  pro bono  unless they are sure it is a guarrunteed win... and that is rare.... Before she gets lawyered up  it would be better if she got her Dr to call the Dr at BCBS who did the medical review and answer what ever  questions he had..... I have done preauthorization/Precert   and it never ceased to amaze me how many treating  Drs would request authorization for a major surgical  proceedure, but would fail to provide the medical to support the need for surgery.... I seen more requests denied because of lack of medical than anything else....I even told the Dr what I or the  Medical reviewer needed to  approve the request....I have even Called the Requesting Dr's office to obtain  his availablity so when the Medical reviewer called they could connect.... so it is not always the insurance  companies that are at fault.... it can easily be the Dr who is requesting the surgery's fault as well. I hope that the Decision for the OP does not take 13 months.... that is a long time to wait

I understand that it can be a matter of paperwork, or even a matter of miscommunication or legislature. But Ive been on this board for a year and a half, most of that time in the Insurance Help room, and believe me, its usually a matter of insurance giving out denials, just as procedure.  Again I say they are wanting her to "go away" and this is probably more than drs not providing supporting info.  Steve

"But Ive been on this board for a year and a half, most of that time in the Insurance Help room" And I have done PreAuth/Precertiification work in both Work Comp and Major Med for 8 yrs.... We all have our opinions....I just hope the OP does not have to wait 13 months...