Denied BCBS Illinois PPO

I'm cross-posting this question from the RNY board when I remembered this is probably where I should have posted this first.

 I guess I am just one of many who've jumped thru l the "hoops" to only be denied but I'm hoping some of you wonderfully knowledgeable people can help me with suggestions on wording my appeal.   I completed all the steps required as stated in their medical policy, including the 6-month clinically supervised diet (all done thru my surgeon's office).  I passed my psych eval with flying colors, etc.  I have a BMI of 46.7 and three co-morbids.  The RNY is very much a medical necessity.  However, the insurance company denied me because I was "noncompliant with the diet as set by my doctor".  Specifically, that I "exceeded the daily caloric limit set by my doctor".  I do not dispute this as I kept an accurate journal of my calories and turned in what I truly consumed daliy.  It does not mean I didn't attempt to reduce calories.  I did and I recorded it in my notes but apparently it wasn't enough.  Has anyone else out there been denied for this reason....noncompliance with 6-mo diet?  I am so frustrated, angry and depressed all in one.  My emotions are so high right now I can hardly think straight because having this WLS is the very tool I feel I need to help me with portion control.  I eat very healthy, just too much.  Finding satiety is my central issue with my morbid obesity.  Am I wrong to be thinking this way? All input and experiences are appreciated. 

That truly sucks - I think I have a sense of how you feel - I  myself received a denial less than 24 hours before my scheduled surgery - my surgeon was so positive it was going to be approved they scheduled the surgery before the final insurance approval came in - disappointed doesn't cover how I felt when that call came.  I felt like all the air had been let out of me.  I felt shame for being in the position  to need the surgery in the first place and then I felt sorry for myself and then I finally calmed down enough to realize I deserved  a healthy life and it is worth it to me to fight for my health. I won at the first level grievance appeal and am set for surgery next Tuesday.  The whole denial process took about a month.  I was lucky - actually blessed because I know it can go a lot longer than a month.

I think I read on this very board that your partcular insurance company is notorious for denying people. Do you have any provision for health advocates for your insurance?  that might be helpful.  If I were you I would at least consider onsulting an attorney - there are some law firms that specialize in helping folks through the obesity surgery appeal process and when I looked at them - I didn't end up hiring anyone because I prevailed at my first level grievance appeal but  I was going to consult a lawyer if I lost.

- the sense I got from some of the obesity law web sites was that they try to keep costs down low.  Some websites noted that most cases could be handled for under $500.  No, I don't work for an obesity law firm - I just googled obesity law and read up on it  - I only thought of it because I have read on the boards that having an advocate can be very helpful...

My particular situation was different from yours as I am seeking a revision from a failed stomach stapling from 22 years ago.  I was initially denied because they said it was a contract exclusion - that was patently incorrect - I read the entire policy and that claim was contrary to the plain language of their own policy.  Next they decided it needed a medical necessity review - blessedly, my insurance - a BCBS - HMO in PA, sends the necessity review to doctors in the particular field and follows their recommendations - I knew that I  fit the criteria and thank goodness so did the reviewing doctors.

 I am an attorney - though not one who specializes in insurance law - my legal training  would have me read that policy very carefully.  Wording counts. What exactly is the wording around the 6 month diet ?  What exactly is the definition of "non-compliance" - is the such a definition reasonable?  Were you able to lose weight during the six month period? What is the purpose of the 6 month diet - were you able to roughly conform to that.

I know that each case is different.  But unless you just totally blew off the six month diet - I think thats a bulls#$#t reason to deny you. 

My guess is that you are going to have to fight them all the way up - does you state provide for an external review of insurance grievances.  Also, I would talk to someone at your state's  insurance department and see if you can file a grievance with them.  In some cases, the squeaky wheel does get the grease - the person who advocates for himself  has a better chance than one who lets "them" make the decisions.

Wow, you've had a much worse insurance experience than I have.  Having the rug pulled out at the point of surgery is one of the worst stories I've heard yet.  I commiserate with you on the extreme letdown of that event.  But congratulations to you.  You are past that horrible point and now just days away from your revision.  Your re-charge will soon begin!

I too had heard how difficult my insurance co is.  Now I know for a certainty it's true.  I felt I had researched and understood the plan's policies regarding WLS pretty well before I ever started this process.  I naively believed that if I did everything they asked I wouldn't be a denied statistic.  Now that reality has struck me with proof once again that all is not fair in war and insurance, I'm sucking it up and working on my appeal letter now.  I too know I deserve this and I am going to fight it.  I just had to lick my wounds for a couple of days. 

If you care to review and provide an opinion I would certainly appreciate your thoughts.  Here is what my denial letter said (beyond the intro part).  This exact same language is on their medical policy (PPO) also. 

Coverage for the surgical treatment of morbid obesity may be considered eligible for coverage when all of the physical, clinical and psychological indications are documented according to BCBS of Illinois' current medical policy.  The request for the surgical treatment of morbid obesity is being denied as the following criteria listed below has not been met:

An expectation that appropriate *comprehensive non-surgical treatment has been attempted prior to surgical treatment of morbid obesity

*Comprehensive non-surgical treatment of morbid obesity appropriateness criteria:

• Documentation of active participation in a comprehensive, non-surgical program of weight reduction for at least six (6) months, occurring within the twenty-four (24) months prior to the proposed surgery and preferably unaffiliated with the bariatric surgery program.  (NOTE: The initial BMI at the beginning of a weight reduction program will be used to meet the BMI criteria for the definition of morbid obesity used in this policy.)
• A program will be considered appropriate if it includes the following components:
  1. Nutritional therapy, which may include medical nutrition therapy such as a very low calorie diet such as MediFast and OptiFast or a recognized commercial diet-based weight loss program such as Weigh****chers, Jenny Craig, etc.
  2. Behavior modification or behavioral health interventions.
  3. Counseling and instruction on exercise and increased physical activity.
  4. Ongoing support for lifestyle changes to make and maintain appropriate choices that will reduce health risk factors and improve overall health.

I am not an attorney but I don't see where compliance is required, only active participation.  That non-compliance word was stated by the CSR at BCBS/IL when she read me the notes written by the medical review unit (when I had called and asked for specifics about the denial reason).  

Once again, thank you Rhonda, for all your help and input.  I am so grateful to have learned about this site.  You and so many others are true treasures with your caring support and fountains of knowledge. 

not speaking as an attorney, because I don't specialize in insurance law and I don't practice in your state - all that said [lawyer cya - can't help it] - its definitely worth a fight.  Active participation isn't perfect compliance and if perfect compliance is what they want, then, they ought to put that in their policy - at least then you would have "notice" as to the requirements.
you made the required doctor's visits I am assuming .  What I would do is ask the doctor under whom you did the diet to write a letter stating that you actively participated and if he/she is willing to restate their opinion that surgery is medically necessary for you. and I would attach it to your letter of appeal.  In your letter of appeal you should address exactly how each component was fulfilled through your program. 
Again, I think these people want you to give up.  Don't .   Its just wrong what they are doing. Let me know how it goes.

Here's a copy of the appeal letter I wrote - my surgeon's office told me it was well written - Initially, I was told it was a benefit exclusion - total BS and I knew it - but then they reclassified as a medical necessity grievance, Please note, the studies I cited I found by googling the procedure and looking at abstracts of scholarly articles.

Dear Appeals Specialist:

           When I called the Independence Blue Cross customer service department to request appeal information, the customer service representative asked me why I wanted the appeal and told me she would submit the information to the appropriate parties.  I wish this letter to serve as my statement of why I believe the denial of coverage should be reversed. I attended at the  Eating Disorder Treatment Clinic in order to better understand my eating behaviors.  I have never been anorexic or bulimic. My therapist with the Eating Disorder Treatment Center, psychologist, Wesley Myers, wrote a letter of medical necessity/support for me having the gastric bypass surgery.   Under the Keystone Health Plan East policy I am enrolled in, Obesity or Bariatric Surgery is a covered procedure under certain criteria - all of which I meet. I am 46 years old and, according to my surgeon, have a body mass index of 51. I have documentation of a failed history of medical weight loss. I am not currently pregnant or breast feeding nor do I have any plans of becoming pregnant. I have had preoperative care at Temple University Hospital which is not only a Bariatric Surgery Center of Excellence; it is certified as a Blue Distinction Center for Bariatric Surgery. I underwent a thorough medical history and physical examination. I have had consultation with a dietician on low calorie diets and exercise. I underwent a psychological consultation with a Temple University Hospital Bariatric Program psychologist and in addition, I am receiving psychological counseling with a psychologist from an Eating Disorder Center. This counseling    It is my understanding I was denied coverage because I underwent a VBG in 1987 at Midway Hospital in West Los Angeles, California and to have a second procedure is a benefit exclusion. Please note, the VBG surgery was not funded by Independence Blue Cross or any of its affiliates. Independence Blue Cross Medical Policy Bulletin #11.03.02e titled “Bariatric Surgery" in a section titled “Second Surgical Procedures" clearly states that a second surgical procedure,   “is considered medically necessary and therefore covered when the procedure is required to treat complications (including those resulting from technical failure) that, if left untreated, would result in endangering the health of the individual."    Specifically enumerated in the policy’s list of common complications are “band" erosion and separation of stapled areas both of which I suffer from.   Dr. Meilahn, the medical director for Temple’s Bariatric Program and the surgeon who would perform the gastric bypass performed an endoscopy on me on November 6, 2008 as a result of the GERD I am increasingly suffering from and to explore the state of my previous procedure. He informed me that there were three areas of technical/mechanical failure of my VBG that needed to be addressed: 1) there is a complete rupture of the staple line which completely defeats the purpose of a restrictive bariatric procedure 2) there is band erosion and 3) the mesh used with the band is somehow embedded in my stomach. I am told Dr. Meilahn was not able to move the endoscope through the banded area of the stomach.    Moreover, it is my understanding that GERD is a related late complication of Vertical Banded Gastroplasty. Within the last several months, I have been experiencing increasing episodes of GERD, generally at least once a day.  I generally treat it with over the counter medications like Prilosec and Tums. Most distressing are the episodes of GERD where I wake up from a feeling of something being stuck in the area of my sternum and bile rushes up into my sinuses.    Separation of  the stapled areas and its ensuing loss of restriction leads to weight regain. As you are no doubt aware, morbid obesity puts at person at extreme risk for a variety of diseases such as diabetes and heart disease – diseases that in the long run are chronic and expensive to treat. In addition to GERD, I am suffering from stiff joints and difficulty standing from a sitting position. I have neck pain and grooves in my shoulders due to the weight of my bust.   Although the Vertical Banded Gastroplasty was the most common and recommended bariatric surgery done in the United States back in 1987 when I had that procedure,  it is not commonly performed anymore because VBG has been associated with a high rate of long-term failure.  The 11^th Edition of  Maingot’s Abdominal Surgery" states:     Early complications after VBG are infrequent, but late complications have resulted in a 17-30% re-operation rate. The most common late complication of VBG is gastroesophageal reflux (16 – 38%) staple line disruption (11-48%)…band migration (1.5%)…Because of the poor long term weight loss and  the high late complication rate, VBG is rarely performed by bariatric surgeons in the United States.[1]    In a long term follow-up study of the VBG by the Mayo Clinic it was found that 21% of those studied suffered with long term vomiting and 16% suffered from GERD. The conclusion of the study was that the VBG is not an effective durable bariatric operation[2] Another study from the Virginia Commonwealth University Medical College, notes that 56% of VBG patients in the study will eventually require revisional surgery after an initial VBG compared to 12% after an initial Roux-en-Y- Gastric Bypass.[3] That same study found that “conversion of a failed VBG to a RYGB is more effective than a reVBG because conversion to RYGB provides satisfactory weight loss without requiring further revisional surgery.[4] An article in the journal “Obesity Surgery" found “conversion to RYGB is effective in terms of weight loss and treatment of complications after VBG."[5]   In sum, I believe the original denial was incorrect because 1) the bariatric procedure I obtained 22 years ago was not funded by Independence Blue Cross and 2) Even if it is considered a second procedure, it is covered because of the existence of mechanical/technical failures, that left untreated endangers my health.   Sincerely,

---

[1] Maingot’s Abdominal Surgery, 11^th Edition, Maingot, Rodney, Zinner, Michael J and Ashley, Stanley W., McGraw –Hill Professional, 2007 pg. 1236. [2] Paper presented at the Forty-First Annual Meeting of the Society for Surgery of the Alimentary Tract, San Diego, CA, May 21-24, 2000 [3] “Conversion of failed or complicated vertical banded gastroplasty to gastric bypass in morbid obesity – Commentary" by Sugerman, Kellum, Demaria, Reines and Mason., “American Journal of Surgery", vol. 171 pp. 263-269, 1996. [4] Ibid. [5] “Revisional sugery after failed vertical banded gastroplasty: restoration of vertical banded gastroplasty or conversion to gastric bypass", by Van Gemert, Van Wersch, Greve, and Soeters, Comment in “Obesity Surgery" 1998, Aug; 8(4): 481-2.
Rhonda

Oops - I tried to cut and paste the letter from Word: I don't know why it came up all scrunched together and parts are missing. I'll try once more - same letter:

As directed in the Independence Blue Cross “Disputed Claim Process", I am writing to formally appeal the decision to deny me coverage of revisional bariatric surgery from a failed Vertical Banded Gastroplasty (VBG) to a Roux-en-Y Gastric Bypass (RNYGB).

 

When I called the Independence Blue Cross customer service department to request appeal information, the customer service representative asked me why I wanted the appeal and told me she would submit the information to the appropriate parties.   I wish this letter to serve as my statement of why I believe the denial of coverage should be reversed.

 

Under the Keystone Health Plan East policy I am enrolled in, Obesity or Bariatric Surgery is a covered procedure under certain criteria - all of which I meet.  I am 46 years old and, according to my surgeon, have a body mass index of 51. I have documentation of a failed history of medical weight loss.  I am not currently pregnant or breast feeding nor do I have any plans of becoming pregnant.  I have had preoperative care at Temple University Hospital which is not only a Bariatric Surgery Center of Excellence; it is certified as a Blue Distinction Center for Bariatric Surgery. I underwent a thorough medical history and physical examination.  I have had consultation with a dietician on low calorie diets and exercise.  I underwent a psychological consultation with a Temple University Hospital Bariatric Program psychologist and in addition, I am receiving psychological counseling with a psychologist from an Eating Disorder Center.  This counseling deals with issues of depression as it relates to food/eating issues.  Although I attended an Eating Disorder Treatment Clinic in order to better understand my eating behaviors, I have never been anorexic or bulimic.  My therapist with the Eating Disorder Treatment Center, psychologist, Wesley Myers, wrote a letter of medical necessity/support for me having the gastric bypass surgery.

 

It is my understanding I was denied coverage because I underwent a VBG in 1987 at Midway Hospital in West Los Angeles, California and  to have a second procedure is a benefit exclusion.  Please note, the VBG surgery was not funded by Independence Blue Cross or any of its affiliates.  Independence Blue Cross Medical Policy Bulletin  #11.03.02e titled “Bariatric Surgery" in a section titled “Second Surgical Procedures" clearly states that a second surgical procedure,

 

“is considered medically necessary and therefore covered when the procedure is required to treat complications (including those resulting from technical failure) that, if left untreated, would result in endangering the health of the individual."

 

 Specifically enumerated in the policy’s list of common complications are “band" erosion  and separation of stapled areas both of which I suffer from.

 

Dr. Meilahn, the medical director for Temple’s Bariatric Program and the surgeon who would perform the gastric bypass performed an endoscopy on me on November 6, 2008 as a result of the GERD I am increasingly suffering from and to explore the state of my previous procedure.  He informed me that there were three areas of technical/mechanical failure of my VBG that needed to be addressed:  1) there is a complete rupture of the staple line which completely defeats the purpose of a restrictive bariatric procedure 2) there is band erosion and 3) the mesh used with the band is somehow embedded in my stomach.  I am told Dr. Meilahn was not able to move the endoscope through the banded area of the stomach. 

 

Moreover, it is my understanding that GERD is a related late complication of Vertical Banded Gastroplasty. Within the last several months, I have been experiencing increasing episodes of GERD, generally at least once a day.  I generally treat it with over the counter medications like Prilosec and Tums. Most distressing are the episodes of GERD where I wake up from a feeling of something being stuck in the area of my sternum and bile rushes up into my sinuses. 

 

Separation of  the stapled areas and its ensuing loss of restriction leads to weight regain.  As you are no doubt aware, morbid obesity puts at person at extreme risk for a variety of diseases such as diabetes and heart disease – diseases that in the long run are chronic and expensive to treat.  In addition to GERD, I am suffering from stiff joints and difficulty standing from a sitting position.  I have neck pain and grooves in my shoulders due to the weight of my bust

 

Although the Vertical Banded Gastroplasty was the most common and recommended bariatric surgery done in the United States back in 1987 when I had that procedure,  it is not commonly performed anymore because VBG has been associated with a high rate of long-term failure.  The 11^th Edition of  Maingot’s Abdominal Surgery" states:

 

 

Early complications after VBG are infrequent, but late complications have

resulted in a 17-30% re-operation rate. The most common late complication

of VBG is gastroesophageal  reflux (16 – 38%) staple line disruption (11-48%)

…band migration (1.5%)…Because of the poor long term weight loss and  the high late complication rate, VBG is rarely performed by bariatric surgeons in the United States.[1]

 

 In a long term follow-up study of the VBG by the Mayo Clinic it was found that 21% of those studied suffered with long term vomiting and 16% suffered from GERD. The conclusion of the study was that the VBG is not an effective durable bariatric operation[2]  Another study from the Virginia Commonwealth University Medical College, notes that 56% of VBG patients in the study will eventually require revisional surgery after an initial VBG compared to 12% after an initial Roux-en-Y- Gastric Bypass.[3]  That same study found that “conversion of a failed VBG to a RYGB is more effective than a reVBG because conversion to RYGB provides satisfactory weight loss without requiring further revisional surgery.[4] An article in the journal “Obesity Surgery" found “conversion to RYGB is effective in terms of weight loss and treatment of complications after VBG."[5]

 

In sum, I believe the original denial was incorrect because 1) the bariatric procedure I obtained 22 years ago was not funded by Independence Blue Cross and 2) Even if it is considered a second procedure, it is covered because of the existence of mechanical/technical failures, that left untreated endangers my health.

 

Sincerely,

 

---

[1] Maingot’s Abdominal Surgery, 11^th Edition, Maingot, Rodney, Zinner, Michael J and Ashley, Stanley W., McGraw –Hill Professional, 2007 pg. 1236.

[2] Paper presented at the Forty-First Annual Meeting of the Society for Surgery of the Alimentary Tract, San Diego, CA, May 21-24, 2000

[3] “Conversion of failed or complicated vertical banded gastroplasty to gastric bypass in morbid obesity – Commentary"  by Sugerman, Kellum, Demaria, Reines and Mason.,  “American Journal of Surgery", vol. 171 pp. 263-269, 1996.

[4] Ibid.

[5] “Revisional sugery after failed vertical banded gastroplasty:  restoration of vertical banded gastroplasty or conversion to gastric bypass", by Van Gemert, Van Wersch, Greve, and Soeters,  Comment in “Obesity Surgery" 1998, Aug; 8(4): 481-2.

You certainly did do your research.  Good going and congratulations on winning your case!  I'm glad you had provisions in your policy from which to refer to in support of your 2nd surgery along with the outside publications and statistical studies on the original surgery outcomes.  I am not a lawyer and so must rely on simple working-wife-and-mother skills although I have tried to incorporate relevant research into my appeal letter.  And the help from all these wonderful OH friends of course.  I do think I have tweaked it as best as I know how.  That is until you just offered up your advice and now I hafta go-n-change and tweak some more.  LOL.  Seriously, thank you again so much for your help and guidance.  You're the best!  HUGS....Pat

My oops now, I meant to add that I will definitely call & talk with my surgeon and request that letter of support.  My husband was saying that same thing earlier today when I used him as my sounding board while constructing this appeal letter but I feel more confident in doing it now that I've had a 2nd on making that move.  When he said it, I kind of felt like that would be in the original submission the insur coordinator sent in.   But then again maybe not and if so that would make it all the more easier for them to slam the door, right?  It can't hurt to have an additional copy since the appeal goes to a different group of people for review anyway.  I will ask for it and the rest of my file when I call on Monday.  I am missing two months of food/exercise logs anyway that she was supposed to have faxed on Friday with the others.  I need the whole picture.  Better to have time to have reviewed it for myself so I can be somewhat prepared for the next possible go 'round in the denial ring.  I'll keep updating as I am apprised of new developments.  That said, now that I have the chore of defending my need for surgery behind me (for a little while at least), my spirits are lifting a bit.  I've read here many times people describe this process as a roller coaster.  That couldn't be more true.  Ya just can't keep a hillbilly girl down for long.  I'm originally from Arkansas and it is there I will return one day once I'm done doing time in Texas.   (ok that's just a family joke, I'm not nor have I ever been a convict.)