HELP! Just now "informed" I probably won't qualify for DS because BMI under 60

[writegirl]

Dear Everyone,

OMG, I'm in freaking tears! I went through all of my requirements for the DS surgery, was told the entire time (seven months) that I would qualify for the DS surgery and just now get a phone call from my surgeon's office to "inform" me that I will probably be denied because BCBS (STATE of Tennnessee employees) insurance "requires BMI be 60" my BMI is just under 50.

I'm fucking outraged (forgive the F-bomb)--how could they let me go all this time believing I would qualify for this. "I'm just letting you know, informing you, that if I submit you for this that if they deny you that's gonna be the reason you're denied." Said to me like no fucking big deal, it's just your life we're fucking with.

@DianaCox @southernlady have either of you heard of this before? Do I have zero say in the surgery I get? I mean, my God, had they told me that from the start I would have intentionally gained weight to get the DS "qualified."

I'm completely horrified. I don't want a gastric bypass. I don't want a sleeve. I want the DS. I want to be able to eat and drink at the same time. I want to have less chance of significant regain.

I'm literally hysterical right now. Any advice will be appreciated.

 

[Larra]

Do you have your EOC (Evidence of Coverage)? This document tells you what is covered and what isn't, and what the criteria are for any given procedure.
Unfortunately, there are policies that mandate a higher bmi for the DS than for other bariatric surgeries. Mostly they go with 50, but some go with 60. It's ridiculous, there is absolutely no medical justification for this, and the DS is standard of care for anyone who meets the usual medical necessity criteria for bariatric surgery, which you do. But yes, we've seen this before.
Your EOC should outline your appeals rights as well, and it sounds like you will need them. But there is nothing to appeal until you get the official denial. So for now get your EOC. You should be able to get it through your HR, or your spouse's HR if your insurance is through your spouse.

 

[writegirl]

Thank you @Larra. I'm so furious with my surgeon's office. They knew I had this insurance from the beginning of my care and kept telling me that I was qualified and that my insurance covers it. My surgeon even said it when I asked him during our consultation whether my insurance covered the DS and he said "Yes and it covers it well." How do they expect people to just rearrange their lives and plans when they are the ones who fuck up and not bother to inform you that you can't qualify for that surgery. My BMI was never 60, so they should have known this from the start.

So, now the surgeon's office is scrambling to gather records for an MRI I had this week because my left foot is growing extra bone and I have a massive heel spur due to my weight. They're hoping that helps with the "medical necessity" part.

I knew something would go wrong with this. I knew it from the start. I just didn't think it would be because my surgeon's office misled me the whole time.

 

[galaxygrrl]

OK....breathe....@DianaCox and @Larra with be able to help! Push through it, don't get sad, just figure out how to make it happen. Just as a plan B. And I had the money, but I had a $8k cap on my insurance to cover WLS and decided instead of fighting with my insurance company, it was just easier to say screw it and go to Mexico. It was 11K and the best 11K I ever spent.

 

[writegirl]

Also, I don't know how my OP posted twice. Oops!

 

[writegirl]

@galaxygrrl I'm a single parent with no child support and a daughter who is a freshman at university. I cannot self pay. I have zero money. It's all I can do to scrape together the money needed for my co-pays and deductible. I don't pay over $350 a month for insurance to have to self pay for procedures that are medically necessary. This should not be something I have to do. I'm just so upset with the surgeon's office because they all should have known this from the very beginning. They knew my BMI was never at 60. They knew I had BCBS State of TN employees coverage. They never should have told me I could qualify for DS if I can't. They should have known.

I'm not sure I want any surgery if I can't have the DS. What is the point of getting a sleeve if it will fail and I'll need surgery all over again? I do not want a RnY because I want to be able to eat and drink at the same time (acid reflux) and I don't want the dumping syndrome issues.

The office manager at my surgeon straight up told me "Just because you don't qualify for the BPD-DS doesn't mean that you would automatically be recommended for a gastric bypass." So, my surgeon might not even recommend RnY and why would he? He recommended the DS for a reason in the first place.

So that leaves me with a useless sleeve option. Why put my body through a surgery that will fail me in the end? I guess I'll just remain obese forever.

 

[k9ophile]

The only words of wisdom I have is that we don't mind the "F bomb" on this site. I know it sounds helpless, yet I have faith in the women we have here who can move mountains and help get the DS approved.

Keep us posted. We are a very supportive community and we support the DS. I realize that not everyone is suited for the DS, but if one wants restriction and malabsorption, the DS is the way to go.

 

[galaxygrrl]

Well, so, clearly fight for the DS, but the sleeve will work. Look at the data on this page, it's just not a well as the DS. - http://www.paclap.com/downloads/comparing-options-for-WLS.pdf So you could get the sleeve and then do a revision if you need it and you might not. But fight for the DS.

Also, I get the issue of you pay for health care and your surgery is NOT covered. I was so pissed about this too. I have a good job and I have good health insurance and they would only cover 8k. It's a business and that is a shame.

 

[DianaCox]

These restrictions limiting the DS to BMIs over X (50, 60) are almost always overruled on external medical review, which unfortunately requires appealing and exhausting your internal appeals first. Larra and I can help you with this.

 

[southernlady]

Okay, get your EOC. A requirement for a high BMI can be fought.

My ONLY experience with BCBS was BCBS TN Medicare which has the same requirements as ANY MEDICARE policy. (35 and over with comorbid, 40 and above without.

It is possible your policy has the caveat but let @DianaCox help you.

 

[southernlady]

I'm fucking outraged (forgive the F-bomb)--how could they let me go all this time believing I would qualify for this. "I'm just letting you know, informing you, that if I submit you for this that if they deny you that's gonna be the reason you're denied." Said to me like no fucking big deal, it's just your life we're fucking with.

And you have a right to be upset. As long as the language passes the filters on the site, no term is off limits as long as it is not directed at another member. If it needs to be, we have other forums for that.

 

[k9ophile]

These restrictions limiting the DS to BMIs over X (50, 60) are almost always overruled on external medical review, which unfortunately requires appealing and exhausting your internal appeals first. Larra and I can help you with this.

Diana and Larra are the mountain movers I referred to in my earlier post.

 

[DianaCox]

Who is the surgeon?

 

[writegirl]

Who is the surgeon?

Thank you for mentioning the appeals process. My surgeon is Dr. Boyce in Knoxville. I'm, quite honestly, shocked that his office would make this error. I mean, he's well-known and they do a zillion of these surgeries a year. That means his office deals with lots and lots of patients who are State of TN employees and have the same insurance I have. I just don't understand how they could make such a mistake.

If I have to appeal this and go through external review, do you know how long something like that takes? I'm freaked out because I work at the University of Tennessee, but I am on the last year of my post doctoral appointment. This means that I can expect to be fired at the end of this semester and I may or may not be rehired as a full time lecturer (despite having taught there for over a decade with excellent evaluations). So, I am worried that my insurance will run out before I get my surgery. I should be covered until the end of July because our insurance package is an annual package.

I'm just worried that I went through all of this for nothing and now I will be caught up in appeals and by the time I "win" I will have no insurance.

 

[writegirl]

And you have a right to be upset. As long as the language passes the filters on the site, no term is off limits as long as it is not directed at another member. If it needs to be, we have other forums for that.

Thank you for understanding. I was and am just so completely blindsided by this that it brought on all the fear/panic/anxiety emotions to the point that the only word that would suffice was fuck. Lol on the "other forums" you'll have to initiate me if it ever comes to that

Seriously, everyone here has been so helpful and encouraging throughout this process. I'm disappointed that the ones who let me down in this situation are the folks over in my surgeon's office. I expected them to know what they were doing this entire time and trusted that they've gone through this so often with so many patients, I assumed they WOULD warn me if there were any reasons I might not get approved before I laid out all this money in tests and deposits and doctor's visits.