My upcoming Appeal for VSG - BCBS Federal

Hi Everyone, 

Yesterday, BCBS Federal called me, the customer rep told me the only reason she could say over the phone about my claims is they were denied because they did not meet criteria.  She said if I wanted a more detailed reason that I would have to request that in writing. 

I'm working on that right now.  I'm going to appeal the denial, I have 6 months to request a reconsideration but I'm not waiting that long.  

Yes, Carmalita thanks for your help sista.    I'm requesting for a Board Certified Surgeon with Bariatric expertise who will be on the board for my appeal.   

My doc wrote a letter of medical neccesity for me.  That's whats going on with my claims.  I did self -pay and now I'm trying to get reimbursed. 

I really regret not insisting my doc to turn in my claim before the surgery.  He told me at that time BCBS Federal would deny it.  That I would have to do self-pay and then they would re-imburse me not them.  Don't really know what the difference is.  He said that is what his other patients BCBS Fed did and they were re-imbursed not for the whole amount but some of the cost, maybe 3K to 4K.   

Of course, I know some of you had no problem with BCBS Federal.  That is my gripe, why do they approve only some FEDs not all.  Thanks for listening to me.

Any comments or tips on how to WIN the APPEAL???

babygirlinokc   

Hi babygirlinokc,

Getting the detailed reason is critical, because that will determine how you appeal - e.g. was it because you didn't meet the BMI reqmts or tht they consider VSG unproven or experimental?  Once you get the written denial, you should also immediately turn around and request the, "information they reviewed to make this coverage decision, including copies of all documents, records, health benefit plan provisions, internal rules, guidelines and protocols and any other relevant information".  They are required to give this to you.

If the VSG was rejected because it was "unproven", it is helpful to note the date of their medical policy, and the last date the VSG portion was reviewed.  In my case, I am on UHC, and the current bariatric policy is dated 12/2007 and the last paper reviewed for VSG was in early 2007 - so for my appeal I put together a summary of the current medical literature demonstrating that VSG is no longer "unproven".  I haven't won my appeal yet, so time will tell!  I don't want to post it on many boards, so you can see it here, or email me and I'll send you a copy: http://verticalsleevetalk.com/insurance-financing/1496-my-ap peal-draft-w-references.html

Good luck!!!

Luanne

 Ms Luanne,

I read your letter and I was greatly impressed.  You really have your stuff together.  I believe you will  win your appeal.  I just might use some of your references if I have to.  I'm waiting for my answer on my appeal.  They received my appeal today.  I'm just doing the waiting game for now. 

Thanks for reponding and sharing.

babygirlinokc

Good luck Babygirlinokc!  Keep us posted on your appeal process, as will I. 

Best regards,

Luanne