Hi!

[nrichard]

I'm new to the site. I have been scheduled for DS surgery in August, but I'm having trouble getting my insurance company to authorize it. I was directed here by a friend who is a member and said I could get great advice on how to deal with the insurance company here. Any sugestions???

 

[Munchkin]

Why were you denied? What are your options for appeal? Post your EOC here!

 

[nrichard]

my PCP referred me to surgery. We have struggled for 6+ years to keep my hypertension under control. I have battled sleep apnea for the last 5 years. Most recently, however I have experienced severe and painful swelling in my legs, which may be indicative of preliminary heart issues. So, upon referral I scheduled a consultation with a bariatric surgery center. I went through all the testing, of course paid quite a bit of money, and filed for a pre-authorization of a DS upon the recommendation of my doctor. However, the insurance company denied it saying that my BMI was only 47 and it has to be 50 in order for them to consider the DS medically necessary. If I was 5'10" instead of 6' I would qualify.

 

[DianaCox]

The BMI over 50 restriction is bogus. We can almost always get that basis for overturned. There is scientific literature debunking it. The DS is standard of care for all BMIs - its superior for BMIs over 50. But we need more info from your Evidence of Coverage and bariatric policy. And is your plan fully funded or self funded? What state controls the plan? Usually where company HQ is located.

 

[southernlady]

Welcome @nrichard
Listen to Diana...she and @Larra are our insurance wizards. Pay attention to what they ask as they really can work wonders with most of the denials.

 

[Larra]

Yes, get your EOC and we'll sort out what your coverage is and also what appeals rights you have. Also, who is your surgeon, and have you made sure that the DS he/she offers is the real standard of care DS and not the experimental procedures that some surgeons are calling a DS (or "modified DS" or loop DS or SADI or SIPS...) which is generally not covered by insurance because it's experimental? Some surgeons are very open and honest about what they are doing, others not so much. Given your serious medical problems, and that you are already having insurance issues, you need to make very sure you are betting the tried and true - and generally covered by insurance - DS. There are already some excellent threads here about this so I won't belabor it here.

 

[nrichard]

I have Blue Cross Blue Shield of New Mexico. I am a teachers so it is through the NM Public Insurance Authority. As far as the headquarters, I'm not really sure. The booklet gives an address in Albuquerque, NM but customer service told me one of my appeals could go to Oklahoma. The surgeon I am seeing is Dr David Syn in Lubbock, TX. I tried to post a link but it wouldn't let me. It states that the DS is not medically necessary for BMI under 50. Thank you for your help!

 

[southernlady]

I have Blue Cross Blue Shield of New Mexico. I am a teachers so it is through the NM Public Insurance Authority. As far as the headquarters, I'm not really sure. The booklet gives an address in Albuquerque, NM but customer service told me one of my appeals could go to Oklahoma. The surgeon I am seeing is Dr David Syn in Lubbock, TX. I tried to post a link but it wouldn't let me. It states that the DS is not medically necessary for BMI under 50. Thank you for your help!

For a DS, you want a vetted DS surgeon. Dr. Ayoola in TX is the only one we recommend.

As far as links, that will happen as soon as you get past 10 posts and a day or so. (stops spammers)

Get your EOC...you have a right to a copy but may have to get it at HR. Then start a conversation with Diana and Larra so they can help you one on one.

 

[Larra]

Actually someone, I think it was @Psychomom posted that Dr. Syn does the real, standard of care DS, so I think you are ok on that point. But we do need the entire EOC to determine both exactly what it says (not what some random customer service rep says it says) and also what appeals rights you have, if any.

 

[southernlady]

Actually someone, I think it was @Psychomom posted that Dr. Syn does the real, standard of care DS, so I think you are ok on that point.

I forgot about that.

 

[nrichard]

Are the EOC and the EOB the same? I can request an electronic EOB, but that's all I can find online and they're closed on the weekend. We have our booklet from almost a decade ago and I can download a updated PDF version, but no where in there can I find the limitations on the DS. I did find mention of the limitation at a general BCBS website under "SUR716.003".

 

[hilary1617]

Hi and welcome @nrichard ! Wishing you all the best on the insurance battle. Hang tough through the many frustrations that are likely to come - the outcome is well worth it.