Insurance denying - Need records I can't come up with

[jas84047]

I've been working on my prerequisites for my Sleeve for almost a year and have been fighting to get it authorized for the past 3 months. I thought I fulfilled all my requirements but after 2 1/2 weeks of waiting for my insurance company to approve/deny they called me this morning. They cannot approve without medical records from my PCP for a 6 month period showing at least 3 visits with weights where I haven't gained - not even a single pound! But... the 6 month Dr supervised diet period does not count! I don't go to my PCP that often. I try not to. I thought that's what they wanted you to do! I've already submitted records from 2012-2013 like requested. I'm livid and freaking out. I've waited and done everything and if I cannot get this covered in the next few months I will not be able to have it until 2016 due to my work schedule. And, by then I will have to start all my prerequisites over because they will be too old. What now? What can I do?



I'm sick about this. And what makes matters worse is I work for the company my insurance is through! I understand all the ins/outs of insurance better than most!



Thoughts anyone? I'm seriously stuck. :'(

 

[southernlady]

Tagging @DianaCox and @Larra

 

[jas84047]

Sorry, I guess I should add a little more detail...


My insurance company is SelectHealth (IHC/Intermountain Healthcare). It's the largest company in Utah. I work for the hospitals side of the healthcare company, but I work closely with the insurance side so I know the process.

There are what's called Case Managers for large procedures or diseases and so it's only one person. I can't really talk to someone else because they will just refer me to my case manager. There's also another 'hiccup' where my SIL is a Case Manager for the company and since none of my immediate family knows I'm doing the surgery (they are vehemently against WLS) I don't want to cause too much of a ruffle in that department to make her aware of it until I have the surgery.

I think the biggest issue I have is the fact that after everything I now have to go to the doc 3x in a 6mo time period just so I can prove my weight?! That seems like a strange and very costly thing to do??

 

[DianaCox]

That is ridiculous. File an appeal immediately. What POSSIBLE information could they get from a weigh in with your PCP that your appointment during the six month doctor supervised diet would not provide? And where is the requirement for those TWO sets of separate and redundant documents, in writing?

In the meantime, get your HR department to provide you with a copy of the Evidence of Coverage document (the full document, not a summary - should be about 100 pages long). And find out whether your plan is self-funded or fully funded.

 

[Spiky Bugger]

What Diana said.

It would be a HIPAA violation for your SIL to mention it to anyone, wouldn't it? Maybe she needs to know that if she does ANYTHING that violates that federal law, you might just lose it completely...and, once you start screaming and yelling, your outburst might just cost her her job. This surgery is THAT important to you.

But then, I'm a bitch*.

Sue

*a bitch who usually gets what she wants.

 

[jas84047]

LOL! Thank you bitch... er, Spiky! Yes, a huge HIPAA violation.

Diana, we are a self funded plan so I realize that makes things even more difficult. I have the full document but there is Nothing regarding bariatric surgery other than it's an exclusion. We just got the bariatric surgery rider added to the employees plan 2 years ago so I know it's covered... however small amounts. I was given nothing in writing directly from the insurance or case manager about my pre-requisites. The paperwork I got from my surgeons office mention Nothing about this 6 months of records showing at least 3 visits without anty gain in the last 2 years. I will admit I did not call the insurance at the beginning of this process and realize that was dumb of me to just go by the list my surgeons off gave me of requirements. I should have known not to trust one person. :/ Plus I really don't have anything to appeal since it technically hasn't been denied yet. They just said they "can't approve my surgery until I send in that other documentation".

 

[DianaCox]

You submitted, they refused to approve. That is a constructive denial. Appeal.

Did you get weighed three times during the six month supervised diet? Submit that.

 

[Larra]

Well first of all Hi and welcome!

Ya know, Diana and I have helped innumerable people with insurance difficulties and you would think we had seen and heard it all, but somehow these damn (yes Spiky I said damn) insurance companies still come up with arguments we have never heard before. I agree, this is ridiculous. Get your policy in writing. If your SIL finds out, so be it. She and the rest of the family are going to find out at some point. Granted you prefer to deal with that at a later date, but if you have to deal with it now, deal with it now.
Personally, I would deal with it by telling them to mind their own damn business (yes, I said damn AGAIN) and I would not let their opinions matter one bit. I figured out very young that there are only a very, very few people in this world whose opinions are worth considering as far as my personal life goes.
And even those very few people may not always agree with how I live my life, and that's ok too. This is your life and your health. Do what you need to do to take care of yourself, and if they don't understand or don't like it, that is their problem, not yours.

PS it would not surprise me at all if it turns out that whoever told you this idiotic requirement got it wrong.

 

[robs477]

Well first of all Hi and welcome!

but somehow these damn (yes Spiky I said damn) insurance companies .

.....Larra said the "D" word, Larra said the "D" word......, TWICE...!

Sorry...but, anyway...BTW, WELCOME to the forum and PLEASE listen to these ladies, they are the best of the best of the best and have helped countless people. It sounds very resolvable to me, BUT, you have to do everything all at once and come back at them hard. My company is self funded also, so, I fully understand your concerns. My best wishes to you!!! Rob

 

[jas84047]

Thanks all for your wise words! I will call my case manager again in the morning to verify it all. I have an appeal already started so if needs be I can send that as well. I also both called and emailed my surgeons insurance specialist and of course have heard Nothing. Honestly, She's the one I dislike the most. She's be extremely lazy and unhelpful.

Diana, I actually asked specifically about using my 6 month diet program weigh ins and she said those do not count. I too was outraged by that but in all reality my weights fluctuated during that even though I ended up with a loss. So, that wouldn't meet the guidelines anyway. Grr!

And yes I know my SIL and family will eventually find out but after some cousins had surgery I told them I was thinking about it and got beaten down and told it was such a "stupid, risky & irresponsible idea". (Although my father is over 400lbs himself) I chose to not have that negativity in my life while I work on my requirements and will tell everyone when I can say, "Haha... screw you-i did it and am so happy!" My husband and friends are all on board and fully supportive though.

 

[more2adore]

What fartknockers! The people who need the surgery the most are the people who CAN'T maintain/lose weight on their own. That's the whole point of surgery. I just want to bang my head against a wall on your behalf!

 

[hilary1617]

I had my first 6 months of Dr. supervised diet determined by my insurance company to be invalid because even though I lost 30 pounds from start to finish as measured by my doctor, I did not have frequent enough weigh-in's and visits for their taste in between. The appeal was taking forever, so I eventually gave up fighting that battle and just moved on to another 6 months of 900 calories a day liquid diet, but that time with weekly weigh-ins by a doctor (a PCP, but not *my* PCP). My insurance company paid for the weekly doctor visits (billed as counselling) and then went on to pay for my DS. Then I had to go through a second of medical clearance appointments that they covered. All in all it took me 18 months to get approved, but it did happen!

I'm sure Diana and Larra have advice for a better strategy than hitting the "redo" button, but if necessary it can be done. Keep your eye on the prize. Hang in there!

 

[jas84047]

So I called and talked to my Case Manager again today to verify what she told me yesterday. I ended up also talking to her supervisor who agreed she was correct. My PCP visits are only every 6 months so the most I have is 2 in a time period. However she sent me a copy of their criteria and I'd like to attach it but I'm not sure how since it's a PDF. I'll try with the upload file button and cross my fingers. I think I can fight it with my 6 mo diet program that is through their company with a dietitian (link to the program: -removed because it won't let me post it -) that my PCP was aware of and that my surgeon told me was the insurance companies requirement. I'd like some input on how to reply to the Case Manager (I have her email now! HAHA! ) so I can forgo starting over. @DianaCox or @Larra ?

I will add when I talked to her the 2nd time this morning I told her I'd just appeal and she stated "there's nothing to appeal because I haven't denied it and won't even put anything in the computer because you don't even meet qualifications to warrant it". I was dumbfounded by that response to say the very least!!!

 

[jas84047]

This is the reply I have so far to the case manager:

Thank you for the info. I have been a patient of Dr Miner for over 13 years and have a great relationship with him. Although I only see him every 6 months currently as requested by him, we email back and forth a lot. I have attached the last few year worth of emails to show just that (printed from MyHealth, fyi- they print backwards his reply then my initial email question so I realize it may be confusing). Dr Miner knows me and all my concerns very well. I always have planned on doing the follow up with him after surgery. I have read and watched every single piece of literature on the subject of the many surgeries as well as the diet, nutrition and follow-up that I can find. I am probably one of the most informed patients because of this, as well as due to my line of work. I realize one of the reasons you want the contact with the Primary Care is for those concerns you mentioned below and I have absolutely no problem with that.


Regarding #4:
It clearly states in #4.2 & 4.3: “Include 3 visits for medical supervision ……. Being provided by an MD, DO, NP, PA or a registered dietitian under the supervision of a MD, DO, NP or PA.”

I believe this should count for my 6 month program through Weigh to Health as those were done by numerous registered dieticians. Dr Miner was aware of and discussed the program not only in my visits but emails via MyHealth, of which I am providing. He also read through the notes from the Dietitians that included all of #4.4 and went over those with me so I was definitely being supervised by my PCP, which is a MD.

If with this info you still cannot approve the requests I ask that you deny it so I can start the appeal process with my attorney.

Thank you for your time.

 

[DianaCox]

Dear Case Manager:

First, this is to advise you that, while I am not represented by counsel, I am getting informal advice from an attorney who helps patients prepare (and win) their appeals for bariatric surgery for her pro bono work.

Second, your attempt to prevent me from seeking appellate review of what you are asserting are Select Health's impermissibly arbitrary and capricious requirements for qualifying for surgery, is itself impermissible and actionable. Your refusal to fully consider and deny my request for preauthorization for surgery is a constructive denial of my request for preauthorization, and any further attempt to prevent me from seeking appellate review from a supervisor having the authority to review will be dealt with as a breach of contract, as well as bad faith denial of insurance, which may subject the plan to punitive damages.

I therefore suggest that you immediate escalate this request for appeal to the appropriate authorities.

For the record, I have FULLY met the requirements in the attached BARIATRIC SURGERY GUIDELINES:

Policy
SelectHealth provides limited coverage for some bariatric surgical procedures when all of
the following considerations are met:

1. BMI > 40kg/m2 MET
OR
2. BMI > 35kg/m2 with at least 2 of the following co-morbid conditions which have not responded to
medical management N/A

a. Medically refractory hypertension (as evidenced by persistent blood pressure readings >
140/> 90 in non diabetic patients and > 130/> 80 in diabetic patients) despite use of at least
2 antihypertensive medications for a minimum of 6 months
b. Dyslipidemia requiring medical therapy
c. Uncontrolled diabetes (defined as HgbA 1 c > 7 on 2 separate occasions at least 6 months
apart despite taking at least 2 diabetic medications with separate mechanisms of action
during this time period)
d. Proven coronary artery disease
e. Obesity/hypoventilation syndrome
f. Obstructive sleep apnea diagnosed with a formal sleep study in an AASM certified sleep lab
interpreted by a certified specialist in sleep disorders​

AND
3. Documented history of BMI > 40 k~/m2 for the preceding 3 years unless co-morbidities present,
then the standard is only > 35kg/m . MET
4. Documentation of active participation for at least 6 months in a structured, medically supervised
nonsurgical weight reduction program. A comprehensive commercial weight loss program is an
acceptable program component, but it must be selected and monitored under the supervision of
the healthcare practitioner providing medical oversight. Comprehensive weight loss programs
generally address diet, exercise and behavior modification (e.g., lntermountain Healthcare's
Weigh to Health Program). MET

a. Documentation from the clinical medical records must indicate that the structured medical
supervision meets all of the following criteria:

1) Occur during at least 6 consecutive months within the 24 months prior to the request
for surgery; and MET
2) Include at least 3 visits for medical supervision, occurring at intervals of no longer than
four months apart, e.g., at the start, middle and end of the 6-month weight loss
program; and CONSTRUCTIVELY MET
3) Be provided by an MD, DO, NP, PA, or a registered dietitian under the supervision of
an MD, DO, NP, or PA; and MET
4) Include assessment and counseling concerning weight, diet, exercise, and behavior
modification; and MET
5) Demonstrate active member participation and engagement resulting in either weight
loss or no further weight gain by the end of the 6 month program. MET​

5. Waist circumference must be> 102 cm (40 inches) in men and> 88 cm (35 inches) in women MET
6. A psychological evaluation confirming patient is a suitable candidate for this procedure with no
significant underlying psychopathology which would impair their ability to comply with
preoperative and postoperative recommendations MET
7. Age~ 18 years MET​

I assert that item 4(a)(2) was constructively met by my participation in a medically supervised six month program. The entire program was thus medically supervised, and the requirement for three separate medical "visits" (note that no specific practitioner is indicated) is arbitrary, capricious, redundant and serves no medical purpose. There is NO indication in this portion of the requirements that this visit be with my PCP as you asserted (without providing any evidence for that requirement), or even with a doctor. My participation in the _____ program is proof enough that I have met the requirements for bariatric surgery.

I submitted my request for preauthorization on ____. Such submissions are required to be answered within ____ days. That time period has already expired/is about to expire. Therefore, I DEMAND that this request be deemed an appeal of your constructive denial of my request for preauthorization, and that you IMMEDIATELY forward this request to the proper authority.