insurance hurdle BCBSNC PPO

I've been told insurance co requires a 5-year weight history and I just got a call from my surgeon's office and they say they have received my medical records but I am missing 2005!  Said they would have to have it since I have BCBS.  Anyone else had a missing year and got approved anyway?  I'm not one to visit a dr regularly, more on an as needed basis, but I can't be absolutely certain that I saw a DR in 2005.  Would BCBS keep records of claims made in 2005 and might I get the information from them?  Thanks for any and all help!

The insurance company will not really help you get records, but they might be able to  ssometimes even dentists ask a patient their weight and document it. Our solution is to get records back even farther is one year is missing. I will include a note to the insurer, "As you can see from the enclosed records, there is no weight for 2005. Mrs. Jones did not seek any medical care during that year, as you can verify with your own records. As you will see from the records provided, Ms. Jones history of obesity has persisted much longer than 5 years." That will help you if you absolutely cannot find one. The worst case scenario is they will deny and you will win on appeal. When a medical director sees an appeal for such a silly denial, you usually win, it's pretty difficult to weigh 300 pounds in 2004, a completely normal weight in 2005 and then 320 pounds in 2006. Sometimes it just gets denied because the nurse reviewer is just really detailed. Good luck! Bonnie

thank you!!

Must be I cannot read. Some of the denials that come into my office are signed by RN's. Sometimes they get denied for lack of information before they even get to the medial director. Anyway, I was relating to my own experiences, I can only speak for the things I see on a daily basis in my job. Sorry for any confusion! Good luck! Bonnie

In our office, our surgeon argued on the phone with a RN nurse reviewer that denied the preauth.  This has happened more than once.  We appealed it up one level and then it was reviewed by a MD reviewer that overturned the denial.  I think the insurance companies are practicing medicine without a license and doing it very poorly.  Sometimes in the denial letter there is a line that offers an appeal to a MD reviewer if the patient requests.  Maybe this varies depending on what section of the country you live in.   Mary 

Wow, I wonder how long it has been since you have actually worked the preauthorization side here?  It really does change from day to day.  We work with primarily self funded plans in my state.  The plan I was refering to is run by a chain of hospitals throughout the state for their employees.  We are not in network and not contracted with them.  However we are the closest bariatric surgery provider and so those employees on this plan are able to come to us.  And yes the RN did deny this preauthorization based on some weight gain during the  MD supervised weight loss program.  I know the RN denied because she told me she was personally denying it and then I was able to get the surgeon on the phone who argued with her the basis of her judgement call.  When we requested an appeal it was finally sent to an MD reviewer who overturned her denial.  Most of any denial letters our office sees contain a disclaimer such as:  this denial is not  to be taken as the decision for medical treatment, that is between the doctor and the patient.  This is only a decision concerning coverage for this service, not medical advice...ya da ya da ya da...... I would like to point to a story that was in the news not too long ago.  Seems that an insurance company in Calif that denied a breast cancer patient coverage for chemo .....based on the fact that she had a pre existing from 10 yrs ago in an emergency room visit.  The woman lived long enough to sue them and win.  Guess what?  They named the person in the Insurance Co, that made 6 figures, who's main job it appeared was to research expensive claims and find reasons to deny coverage.  I am sure I could google up that news article....not urban legend.   The sad fact of the matter is that Insurance, managed care, whatever you want to label it.....is taking a lot of money for little to no service.   I would have loved to have a tape of the phone call I had with a medical review nurse for a national company.  When I pushed for the criteria for medical necessity, she finally said Geesh....just do what I do on some of these plans.   When it is not specifically stated in the plan certificate I just google gastric bypass criteria and use whatever comes up.  Honest it really happened.  I don't think it is an accident that when you call an insurance company to verify benefits you are left getting the opinon of a customer service rep trying to interpert a plan certificate.  Some say...well it looks like an exclusion or maybe it's covered just send in a preauthorization to find out.  Where is that person in claims when the bill is sent in that always knows yes or no?  Why can't we ask based on the procedure code or diagnosis code?  As of late we are finding that they suddenly go back years looking for any lapse of coverage....to scream pre existing.....We  change our questions to them frequently concerning benefit coverage to include whatever they have come up with for a loop hole.  I spend a lot of time just tracking each company for changes and twists and turns.   If I were to stop what I do for just one month I would miss valuable info that had already changed and some one could get denied or worse find out after the procedure that coverage would not be there.  I would love to believe that things were staying just where you say they are.....it wouldn't be so disheartening as my world is.  However I play the insurance game for our patients and 95% get thru with a pre authorization approval and go on to have surgery.   I feel good about what I do slugging it out in the "trenches."  Most people do not realize how much has changed and very quickly I must add.  Whatever you are still thinking that medical review decisions are bound by legally I could show you  a loop hole that they invented to get out of it.   I am sure you won't agree with me but just for a moment listen  to the reality of this  from someone who is on the phone hours each day actually doing this.   I would also like to add that I deal every day with honorable good people in the insurance industry.  Many really do try to help answer our questions but literally cannot access the information.  Many almost cry with me when a denial comes down and they also can do nothing about it.   When I refer to the insurance industry I do not refer to them. Mary

I am just adding a link to the story I was refering to.   There are many more.....not urban legend anymore.   http://abcnews.go.com/GMA/OnCallPlusBreastCancerNews/story?id=4338818 Mary