Anyone get denied? And/or was self-pay?

[Stefanie S.]

So a week ago, insurance (BCBS of NC) denied my surgery. I am a revision - going from sleeve to DS. They first denied because of some new rule change on Jan 1 about a 12 month requirement. My surgeon (Dr. Sudan) didn't feel that I should have been denied based on that. He had his staff resubmit. That was last Thursday. BCBS said they have until Monday at 5pm to get an answer back as it was escalated to their medical director. Surgery is supposed to be the very next day. How will that work?

I found the policy and looked it over. It does say that a 2 stage process is not covered, i.e. going from a sleeve and later to a full DS. BUT BCBS didn't pay for my sleeve. I did, out of pocket. I've been in a fog. I can't believe they let you go 6 months through ALL of that pre-op stuff. All of the time and money already spent, and then they deny you last minute.

Well, I am quite fortunate in one aspect. I have a grandfather who said he will pay for my surgery if insurance denies it. I have already flown my mom in from Kansas to be with me this week so ideally the surgery will still happen on Tuesday (24th). I only found this out from my grandpa yesterday so I have to wait until tomorrow to talk to everyone about the possibility of self-pay. My question is..... has anyone else done this? Do you think if it's paid via credit cards and cash (however that works?), that this surgery could still happen on Tuesday?

Bummed in Raleigh, NC
Stefanie

 

[southernlady]

So a week ago, insurance (BCBS of NC) denied my surgery. I am a revision - going from sleeve to DS. They first denied because of some new rule change on Jan 1 about a 12 month requirement. My surgeon (Dr. Sudan) didn't feel that I should have been denied based on that. He had his staff resubmit. That was last Thursday. BCBS said they have until Monday at 5pm to get an answer back as it was escalated to their medical director. Surgery is supposed to be the very next day. How will that work?

I found the policy and looked it over. It does say that a 2 stage process is not covered, i.e. going from a sleeve and later to a full DS. BUT BCBS didn't pay for my sleeve. I did, out of pocket. I've been in a fog. I can't believe they let you go 6 months through ALL of that pre-op stuff. All of the time and money already spent, and then they deny you last minute.

Well, I am quite fortunate in one aspect. I have a grandfather who said he will pay for my surgery if insurance denies it. I have already flown my mom in from Kansas to be with me this week so ideally the surgery will still happen on Tuesday (24th). I only found this out from my grandpa yesterday so I have to wait until tomorrow to talk to everyone about the possibility of self-pay. My question is..... has anyone else done this? Do you think if it's paid via credit cards and cash (however that works?), that this surgery could still happen on Tuesday?

Bummed in Raleigh, NC
Stefanie

Bummer...and this is why we tell people to not count on a two stage operation. Many insurance companies have a one surgery per lifetime rule regardless of who paid for the first one.

What I would do is go ahead and self pay WHILE you fight the denial with @DianaCox & @Larra's help. That way, if they finally approve, you can get reimbursed and pay your grandfather back.

You have an awesome grandfather willing to do this to help you.

 

[DianaCox]

If you have formally been denied in writing, your appeal rights are vested. You can go ahead and self pay, and pursue reimbursement afterwards, keeping in mind the deadlines for the filing of the appeal.

You are not a two part surgery. You are a revision of a sleeve, which was (however futilely) intended to be the definitive procedure.

 

[Stefanie S.]

You are not a two part surgery. You are a revision of a sleeve, which was (however futilely) intended to be the definitive procedure.

That's exactly what I was thinking. I didn't start out thinking I was getting a 2 stage procedure. I hope that medical director (who apparently gets to play God in this situation) sees it that way. They also said they have to see definitive proof that I was compliant to my last surgery's requirements. Well... I did show that I went to all of my post-op appointments and had all necessary labs done. I did not however go to the post-op groups and I eventually could not stick to 1200 calories only per day. I had gone to my surgeon at one point to seek help and discuss this with him and his dietitian. I hope that doesn't bite me... I had admitted to eating 2000-2500 calories per day. If that's in the notes, then I might be out of luck?

 

[Stefanie S.]

Bummer...and this is why we tell people to not count on a two stage operation. Many insurance companies have a one surgery per lifetime rule regardless of who paid for the first one.

You have an awesome grandfather willing to do this to help you.

Yes, my grandfather is the most giving, loving man in the world. He had me in tears with this offer. I refused at first, but he convinced me. And you are so right... I will be sure to warn everyone in the future about this if it comes up - do not do sleeve if there's even a 1% chance you are going to later want a revision!

 

[-Flo-]

I was also a VSG to DS revision. BCBS denied me at first. I self paid and my surgeon won my appeal. I will be getting reimbursed any day now.

 

[Stefanie S.]

I was also a VSG to DS revision. BCBS denied me at first. I self paid and my surgeon won my appeal. I will be getting reimbursed any day now.

Really? This gives me so much hope!

 

[-Flo-]

Really? This gives me so much hope!

I was shocked when I got the letter. But, yup they paid. Now getting the money back from the hospital is taking forever! I'm 9 months out and I still haven't received the check. And yes, I have been calling them.