BCBS/IL PPO Denial #2 !!!

Well folks, I got the unlucky draw for sure.  That's how it feels anyway.  First denial reason was "non compliant with diet" which was BS, I lost 17 lbs over my 6 month supervised WL program.  I wrote a lengthy, thought-filled appeal to that and today the mailman brought me denial letter #2 dated 03/27.  I swear they make it up as they go along.  This time I'm not depressed.  Now I'm in a rage at the "new" denial reasons.

Apparently they concede that I was compliant with my 6-mo diet program but now they are denying me because they say I provided my own weight history for the year 2004 so I don't have 5 yrs proof of morbid obesity and that I didn't get a psychological evaluation.  WTH?  All my records came from my surgeon's office to them, which came from my doctors, not from me.  And yes, I did get a psych eval in February from a PhD no less, not just a licensed clinical social worker, AS THEY REQUIRE under my plan.  They should know because they paid the claim but did so under the wrong benefit structure.  This is straying off my rant about the 2nd denial but want to share it here to show the pattern of ineptitude on their part.  There were numerous phone calls between myself, the insur & this psych docs insur coordinator prior to the appt to determine what my plan required.  As a Psychologist (has PhD designation) this doc is out-of-network even though BCBS shows her as in-network on their online provider list (which the insur later admitted was an error & they would have to fix....and they still haven't).  As a licensed clinical social worker, a designation this doc also has, she would have been in-network BUT my policy requires the more expensive, out-of-network, PhD designation psych eval.  Of course they do, so I shelled out the $245 required by psych doc as I was literally 5 minutes from appt time when the insur co called me to say "oops, we made a mistake, this will be out-of-network benefits".   I would have had to pay a cancelled appt fee anyway, plus lost time from work, so of course I went ahead with the appt.  It's not like there was anyone else available anyway.  Six weeks after the eval (which I passed by the way), I get an EOB from BCBS/IL and they have paid her as in-network and show my co-pay was to have been only $15.  I called and told BCBS about the screw up and they insisted they paid correctly and the doc would have to reimburse me.  Yeah, that hasn't happened as they continue to argue that the money I paid them directly was the correct benefits.  I guess I was screwed out of $245 because BCBS/IL provided me with the wrong benefits AND now they are screwing me again by saying in my 2nd denial letter:  

  "Medical necessity cannot be determined without completion of a thorough multidisciplinary evaluation, which would include a psychological evaluation as well as a TSH (thyroid stimulating hormone) level to rule out treatable metabolic causes of obesity."

Gimme a break!  Pad the walls, I may make a run for it head first. 

And what's up with requiring a TSH level?  Anyone else had this required of them by their insurance company?  This is not spelled out in my Medical Policy as a criteria for medical necessity.  Not that I'm adverse to getting blood work done, and I think I understand where they're going with this TSH blood work thing but  it's a waste of time and money for me and them as I had this done just last July in the process of various tests & procedures to discover that I have complex hyperplasia without atypia (no cancer---T/U for small blessings).  Guess I will have to get records from my GYN now to show them that too even though they paid all the claims for all the tests, surgery & treatment.  Yes, I realize that they don't review my claims history, just that it seems like they would if this was a flag to them.  And funny, back then I actually had kind of hoped I would have low TSH levels because a thyroid issue would help explain some of my weight battle.  No PCOS either for those who are wondering.  After those were ruled out I knew then that I had to move forward into this WLS journey.  No more excuses left for me to blame it on.

Sorry for the long rant.  This insurance company is just full of you know what.  Anything to put people off and frustrate the living daylights out of 'em.  Come Monday, my phone line will be glowing red for all the calls I will be making to my surgeon's insurance coordinator and BCBS/IL.  And possibly to an attorney.  Thanks for listening (reading).

 Sorry you are going through all of this. Insurance companies are evil and truly suck. 

I would suggest that you hire an attorney, because you are already on appeal #3. You only get so many appeals through your insurer. That being said, do you know if your state offers an external appeal? Some states offer an external appeal that's done through an independent party. If you don't have that option I would really suggest you hire that attorney.

Your insurance is just trying to make you go away. They hope that if they give you a hard enough time you will give up, or die before they have to pay up. Don't lose hope, many of us, me included have to fight to get the benefits we deserve. I wish you the best of luck.

Thanks for the advice.  Actually, I have only filed one appeal......I've been denied twice.  The first denial was the predetermination of benefits that my surgeon sent in.  That was a quick "no" and that's what I appealed first as it wasn't a simple missing document kind of thing.  I am calling both surgeon & insurance on Monday and will see if I can get an insurance advocate rep.  I definitely feel the insurance company slamming the door in my face but I'm going to keep knocking till I get what I know is legally available and medically necessary for me.  I have jumped through all their hoops and met all their criteria.  It is time for them to do their part.  (Give approval and pay up per my policy.)

I am fighting my BCBSTN exclusion policy with the help of WWW.obsitylaw.com. They tell me that a lot of your success in appeals is all in how your policy is worded. You can call or email their site and they can tell you if they think they can win an appeal for you for free. If you hire them they have a payment plan for their fees and will consider any reasonable payment plan you suggest. 
The other poster was correct;insurance will  send you on as many goos chases as they can. Try to stay calm and simply provide them with all the info they ask for. Eventually there will be nothing else they can stall for.Good luck,
Holly

Did you ever get an approval? I am fighting BCBS/IL right now as well.

Yes, finally.  I had surgery 05/18/09.  I'm now 100 lbs down and living life to the fullest.  I really need to update my personal blog on here.  You should go there and read all my old blogs.  I was pretty good in the beginning to cover my journey.  The further out you get the more "regular" life becomes and a lot of us seem to drift away from obesity help a bit. 

As far as the insurance fight, it was a hard battle to be sure.  Both before and after surgery but you have to hang in there.  Appeal your denial with all the reasons why you DO qualify.  Just be prepared emotionally, I had to do it twice.  I re-read and took from their website the section on qualifying for weight loss surgery - like when they said I hadn't been compliant with my doctor supervised diet, I pointed out I had followed and completed his program exactly.  A specific amount of weight loss was not a criteria stated in those insurance qualifications so that denial didn't hold up because they didn't list it.  I met all the other qualifying reasons for WLS:  I had multiple co-morbidities (diabetes, high blood pressure, hyper lipedemia).  Construct your letter in such a manner that you cover all your health issues point by point, including how your current state of obesity negatively affects the quality of your daily life.  I wore slip on style shoes because I couldn't bend over to tie them because of my large stomach.  I couldn't walk a flight of stairs without losing my breath and heart pounding.  Describe in detail exactly how you feel every day.  You have to convince them.  No one can do this better than yourself.  Don't feel like you're being gross or too personal either.  They need to know graphically - these are doctors  that review these records anyway, they've heard/seen it all before so don't be afraid to list personal details that make daily life unbearable for you.  List all the diets you have tried (and failed at) too.  Ask your surgeon if he will give you a supporting letter of surgical need.  Attach copies of any previous diet plan records if you have them, doctor's records that show the diagnosis codes for any co-morbidities, recorded weight, etc.  My second denial was for not having proof of a 5-yr weight history showing morbid obesity.  Thank goodness I had an emergency room visit and was able to get a copy of those records that proved to them I had been "fat" long enough.  It's just ridiculous what some insurance companies will put you through.  Again, hang in there.  Write that appeal letter and mail it off and then be patient.  I know that's hard too - the waiting. Total time for me from when my doctor submitted my stuff to insurance to the time I was finally approved was 3 months.  It was pure agony for me.  If I can help you in any way, let me know.  I would be glad to pay it forward.  I had help with mine from another obesityhelp member.  This is a truly great website for anyone on a weight loss journey. 
Hugz - Pat

OMG im reading your post and going through the same exact thing you went through.  My coordinator sent in all my paper work and they denied me requesting proof of diet and exercise.  I then went to my gym and my nutritionist for all of my notes and proof and they still denied me.  Then they recommended a Peer to Peer with my Dr and they continue to deny me.  Now I just fed ex my appeal to see what happens next.  If you dont mind me asking what did you do after the appeal was denied.  My insurance advocate got involved but she was no help because all she told me was that the notes from my nutritionist was more in depth than my PCP.  She told me they want all my notes like the nurtionist notes.  I told her no where in the policy requirement does is show what type of notes need to be taken.  Straight BS.  Now I have to wait to see the out come of the Appeal.  What did you do after you got denied with your appeal?  I see you did end up getting surgery.  How long did it take for you to get Approved?

I was denied twice by my insurance co.  On each denial, I wrote an appeal letter addressing exactly what they had spelled out as their reason for denial.  I had to take it point by point.  In my case, each instance they had one reason for denial so it was fairly simple to respond to that.  Basically you parrot their language a little bit.  Like when they said I had not been compliant with the 6-month doctor supervised diet, I replied I had followed the criteria set forth by my doctor and nutritionist's plan but I was unable to maintain the very low calorie diet plan due to my large volume stomach capacity.  In my doctor's office, we had to keep a diary of everything we ate, calculate the calories and an exercise log.  When that was presented to the insurance company on the first submission it's like they pistol whip you with that information so instead of getting mad and giving up (OK, I was mad & emotionally wrecked at first but I put on my big girl panties & fought back), I humbled myself and said (in my appeal) that this doctor's supervised diet was yet another example of a failed diet attempt and that the RNY surgery is what I felt was the best choice to help me in controlling my hunger thru reduced capacity.  I also listed all my health issues and how daily life was difficult for me.  You really have to put yourself out there in these appeal letters.  Defiance & threats won't work.  If you have met the insurance qualification criteria they have no choice but to approve you.  It's a hard and rocky road for some of us.  I really feel they are just trying to get people to give up.  Those that do simply means they don't have to pay out anything and therefore that money is in their pocket.  It takes a lot of medicine & dr. visits to accumulate to a $65k surgery (what my surgery would cost without insurance).  And we know these insurance companies are in it for the money, not because they truly want you to have a better quality of life.  Sad but true.  Hang in there girl.  If you are denied again and want help answering, contact me again.  I'll be glad to help if I can.

Thanks for the info.  The Lindstrom's will be my next contact if my round of calls on Monday prove unsucessful.  I was so upset and angry when I got this letter yesterday I focused on the negative instead of thinking like a lawyer.  I have met BCBS/IL criteria per their Medical Policy.  They are just jacking me around and I know it.  It's for this very reason that I'm so upset because I thought I had done everything "right" from the beginning.   After calming down a bit late last night, I re-read it again......several times.  I finally saw that they do state in the letter that  if I or my physician can supply them with additional clinical information (the psych eval and TSH level, both of which I have), they would re-open my appeals case upon receipt.  However, I imagine after I do that they will probably come up with something else to put me off .  But everybody reading this, please say a prayer for me that once I give them this info they will be satisfied and approve me.