Question:
I need help with my appeal letter to BCBS (appealing DS denial)

Is there anyone out there who has been denied the DS by Blue Cross Blue Shield of TN (I have Blue Preferred PPO through the State of Tennessee) and successfully appealed? Especially since this relatively recent "zero tolerance" policy they seemed to have adopted. You can email me at [email protected]. I need to know that there is some HOPE that this appeal will work!    — [Deactivated Member] (posted on August 2, 2001)

August 2, 2001
Also, why does FEDERAL BCBS approve it, when the others won't????
   — [Deactivated Member]

August 2, 2001
Why did they deny it...did they say it sas "experimental", "contracually not covered", related to non-covered "obesity" services.....
   — [Anonymous]

August 2, 2001
In the letter that I had them fax me, it says that DS is "investigational." What a crock! Before I got the letter, on the phone, the woman told me that it wasn't medically necessary...HEEEELLLLO...I'm 199 lbs. overweight! But she did say that the RNY was approved. Today, when I called to get the correct procedure for appeal (don't want them throwing it out for any red-tape reason) I was told that 1)It was considered investigational, 2) It was excluded in my plan (not true, the only exclusion is for, and I quote, "non-surgical weight loss methods") and 3) Be happy, cause I *could* have an RNY! I am not downgrading RNY at all...it is right for some people, just not for me....and I won't settle for anything less than what is right for me, it is too important of a decision.
   — [Deactivated Member]

August 2, 2001
Hi, I am in a similar situation. BCBS of Mi denied me the preauthorization for the DS(long limb, 200cm) CPT code 43847. This is the procedure code my surgeon does. They say this is investigational. They tell me the DS ,CPT code 43846, short limb,( 100cm or less) is convered. I have an appt with a surgeon across the state who does the short limb DS. I will see him on Aug 17th to pursue this possibility. I have appealed to BCBS and have until 8/17 to go the next step in the process,which is to request a managerial level conference. I may do this and then wait to see how my DR appt goes. One of the folks on this site wrote me to tell me that if BCBS denies on the basis of a procedure being experimental that even if it goes to an outside reviewer there is virtually no chance in getting it reversed. I have also talked to Walter Lipman re this and am considering utilizing his expertise. It is hard to know what to do. I really just want to spend my emotional energies getting me the best possible care and focusing on prepariogn for surgery and healing after. going through the insurance maze is, in my humble opinion, "Dangerous to your health." I hope you are successful or can find a good alternative. Blessed be, Good Luck, Kathy
   — kathleen S.

August 6, 2001
I certainly hope your appeal is successful. But, speaking as someone who works in this area professionally, there is virtually no chance that bcbs will pay for a procedure deemed to be "investigational"; particularly when there is approved method available to you.
   — [Anonymous]

August 6, 2001
Well, we'll just have to get that "investigational" status rectified, won't we?
   — [Deactivated Member]

August 6, 2001
Misty, I too was denied the DS by BC/BS of TN -Blue Preferred. I appealed and lost...even though another person I know was approved for the DS with the same plan as me. They suck big time! They actually told me that this other person's approval was just a mistake. I ended up going with the RNY. E-mail me with any questions at [email protected]
   — Tina K.