BMI is 47. How to get BCBS IL to pay for Duodenal Switch.

[irishmom1972]

Hello. Thanks everyone again for your suggestions about getting BCBS IL to pay for DS. I had no luck with getting the EOC (explanation of coverage). I called BCBS and they read the Medical Documents to me. My surgeon's office read the medical documents off of BCBS's website, and everything clearly says,

Duodenal Switch Surgery is NOT considered medically necessary for patient with BMI's under 50.

My husband and I have had a rocky marriage for years. He carries the insurance and is really being no help to me about asking his HR department to retreive a EOC document for Weight Loss Surgery. My husband could care less if I get the surgery or not. I just had a sleep study and have been diagnosed with obsturctive sleep apnea. I have migraines, fibromyalgia, low back pain and knee pain too. According to many people I've talked to including a member on a FB WLS board who works at BCBS IL in the claims department said that BCBS will deny, deny, deny because my BMI is under 50. Is this a fruitless effort? My BMI is 47 right now. I'm only 20lbs or so away from a BMI of 50!! I'm so close, but I know BCBS will be black and white when approving/denying it. At my heighest I could have been a 50 BMI but it was never officially documented. There's a ton of cancer, diabetes, heart disease, and high blood pressure in my family too. None of my own cormidities seem like they'll help my case, nor will my family history.

I'll still try to fight this with insurance, but there's a risk that WLS won't even be covered next year, so I feel like I'm running out of time. With six young children on one income and with a husband who's not supportive, i can't go fly to Mexico and pay out of pocket...don't have money or a trustworthy caretaker for my children while I'm recovering, etc.

Any suggestions? I think the key is to prove to BCBS that DS is medically necessary for me, but I don't know how. They'll just tell me to go get bypass or something, which is covered.

My surgeon is on board and he says that it's not up to the insurance company to determine what type of surgery I need, but I know that's all talk. If I can't pay out of pocket and can't go to Mexico to even have an affordable surgery out of pocket, I don't have the time or a sitter for my kids. So the insurance will try to drive this decision. Any help here? My surgeon does way more gastric bypasses (the Kane Center in Hoffman Estates, IL). I have an appt. with the University of Chicago team this week to discuss DS, but they told me up front that they typically reserve DS surgeries for BMIs over 50 or if it's under BMI ...for those with severe diabetes. I know U of C is a a great hospital to get DS surgery but I wonder if it's a waste of time for me to even go to them if they told me up front that they typically don't do DS surgeries on my type of patient profile. I wonder if my history of multiple rounds of IVF and feeling like my hormones & metabolism are all screwed up would help me with my case...to prove that DS surgery is medically necessary for me.

 

[Felicity]

Not sure if this will help, but I work in the same area within my employer as the HR department. They take calls and answer questions from covered spouses about benefits. If your husband's company is larger, you might be able to contact them yourself since he's not being much help. Figured I would suggest that -- as to your other questions, I am sure the vets around here will be of more help! Good luck!

 

[irishmom1972]

Just curious, how is this EOC document more informative than the medical policies that I've already read? How will the EOC document help me get the duodenal switch surgery covered? Will it contain information that explains what needs to be proven in order for me to prove that it is medically necessary for me? Wondering how this EOC document is more informative than the medical policy about duodenal switch and how it will help me?

 

[DianaCox]

Please contact your husband's HR department and tell them you are entitled to receive a copy of YOUR insurance, even if it is through your husband's benefits. If they refuse, contact your state department of insurance. You also need to find out from them whether the plan is self-funded or fully funded - your rights are more limited if self-funded.

Are you in IL or in another state? You will likely need to exhaust your internal appeals (probably appeal the initial denial, then appeal that denial and get denied again) before you are able to appeal to the state department of insurance for an independent medical review. THAT is where you are likely to get justice. So you are going to have to research the applicable laws.

Their restriction is not justifiable. The ASMBS has deemed the DS as a standard of care procedure for ANYONE who meets the criteria for bariatric surgery. It is NOT limited to SMOs. http://asmbs.org/resources/consensus-statement

 

[irishmom1972]

Please contact your husband's HR department and tell them you are entitled to receive a copy of YOUR insurance, even if it is through your husband's benefits. If they refuse, contact your state department of insurance. You also need to find out from them whether the plan is self-funded or fully funded - your rights are more limited if self-funded.

Are you in IL or in another state? You will likely need to exhaust your internal appeals (probably appeal the initial denial, then appeal that denial and get denied again) before you are able to appeal to the state department of insurance for an independent medical review. THAT is where you are likely to get justice. So you are going to have to research the applicable laws.

Their restriction is not justifiable. The ASMBS has deemed the DS as a standard of care procedure for ANYONE who meets the criteria for bariatric surgery. It is NOT limited to SMOs.

Thanks so much, Diana. Yes, I live in NW Illinois. I'm not quite sure if his plan is self-funded or fully-funded. It's a smaller engineering company (maybe 300 employees?), so I'm thinking that it's probably self-funded?? Could you please explain how that will limit my rights if his plan is self-funded?l truly appreciate your sharing your knowledge. I will call his HR department tomorrow. I'm just wondering why the EOC is so important to track down. All of BCBS's Medical Policies (even when I called BCBS and gave them our policy number and group number)thus far have stated that "Biliopancreatic bypass with duodenal switch is considered not medically necessary as a treatment for patients with a BMI less than 50kg/m²."

BIG QUESTION: My husband's employer is small and they tend to change their insurance policy from year to year. November is always the month that they change policies, coverage, etc. Even if they announce changes to my husband at his annual meeting, it doesn't mean that he'll come home and tell me about the changes. There's a chance that his insurance will change Jan 01, 2016 and Bariatric Surgery might not be covered at all in 2016. I'm just feeling pressured to get this all taken care of before the end of the year before that happens (i.e, get surgery before next year if his insurance plan doesn't cover bariatric surgery at all in 2016. So, if an appeal is already in the works for 2015 and they still deny, deny, etc. andd worst case, if the State denies me for an Independent Medical Review -AND- if for some reason my husband's plan doesn't cover Bariatric Surgery next year, could I still fall back next year and plan on using their 2015 benefits (when the appeal took place) and have the insurance-paid sleeve gastrectomy? I'd rather have something than nothing if this appeal process takes place past December 31, 2015. I couldn't pay for the surgery myself.

My husband thinks that I just need to shut my mouth,quit eating and that the thought of this surgery is ridiculous and will just keep him away fro work during my downtime. Regarding going to Mexico for DS surgery if it ends up not being covered, he said that I need to forget about thinking about paying out of pocket because we don't have the money. So, I’m on my own fighting this battle with insurance and for getting this approved. If this appeal process goes into next year and if there's no WLS coverage on a new plan next year, I'm really out of luck.

 

[Txkat]

In Illinois, bariatric surgery is considered by law to an essential health care benefit. I would seek out a surgeon that does a large practice in DS surgeries and could advocate for you in a peer to peer review. My BMI was only 36 at the time of my surgery, and SIPS was not even a covered procedure by BCBS at the time of my surgery. I managed to get a helpful person in BCBS appeals to schedule a peer to peer review with my surgeon and the Medical Director at BCBS less than a week after my denial letter. After discussing my case, I had an approval the same day. I believe the key is having a surgeon to advocate for you who believes that the DS is the best option for you. If your surgeon does a lot of bypasses, he obviously isn't sold on the benefits of the DS. My surgeon only does sleeves, SIPS, and DS surgeries. He's the head of the bariatric unit at Duke University, and has said that the lap band and bypass both have more complications and weight regain in his experience. He is the person who is responsible for getting SIPS procedure covered by BCBS based on the study that I have been participating in. " if your only tool is a hammer, every problem looks like a nail"...

 

[Felicity]

My husband thinks that I just need to shut my mouth,quit eating and that the thought of this surgery is ridiculous and will just keep him away fro work during my downtime.

I'm sorry that your husband is such a jackass. Good for you to seek this out even without the emotional support of your spouse.

 

[irishmom1972]

I'm sorry that your husband is such a jackass. Good for you to seek this out even without the emotional support of your spouse.

Thanks Felicity. I knew I wouldn't have his support, I never do. He has Aspergers but that's a completely different story. He's negative and never a team player nor is he ever encouraging. I had no luck getting a hold of his HR manager live on the phone today...kept getting her voicemail and I didn't want to leave a message. So I spelled out exactly what I needed for him to get for me from her today and asked him to walk in her office. Of course, he was frustrated to have to do something for me. He ended up sending her an email and not even going into her office. The HR person directed him to BCBS IL's website about Bariatric Surgery, the generic document that I found a couple weeks ago. My husband briefly stumbled across the minimum BMI requirement of 50 for DS, and he remembered that I mentioned that I'm not at 50. Then he kept rubbing it in my face how BCBS clearly states that my BMI has to be 50 and that I "might as well forget about getting that surgery." He's never had my back and expects me to roll over too and just give up. It's sick, but I know he gets some kind of gratification when I want something and can't get it. He could care less about something this important to me, and like everything else that I ever wanted or aspired to do, he's the biggest naysayer. Yes, I'm definitely fighting this battle alone and am only expecting discouragement out of him.

 

[DBmom23]

Irishmom, perhaps your height needs to be rechecked. You are so close to 50 that a half inch could make a difference.

 

[southernlady]

Thanks Felicity. I knew I wouldn't have his support, I never do. He has Aspergers but that's a completely different story. He's negative and never a team player nor is he ever encouraging. I had no luck getting a hold of his HR manager live on the phone today...kept getting her voicemail and I didn't want to leave a message. So I spelled out exactly what I needed for him to get for me from her today and asked him to walk in her office. Of course, he was frustrated to have to do something for me. He ended up sending her an email and not even going into her office. The HR person directed him to BCBS IL's website about Bariatric Surgery, the generic document that I found a couple weeks ago. My husband briefly stumbled across the minimum BMI requirement of 50 for DS, and he remembered that I mentioned that I'm not at 50. Then he kept rubbing it in my face how BCBS clearly states that my BMI has to be 50 and that I "might as well forget about getting that surgery." He's never had my back and expects me to roll over too and just give up. It's sick, but I know he gets some kind of gratification when I want something and can't get it. He could care less about something this important to me, and like everything else that I ever wanted or aspired to do, he's the biggest naysayer. Yes, I'm definitely fighting this battle alone and am only expecting discouragement out of him.

Call her yourself. Tell her you need a copy of the document they give to employees every year that spells out THEIR personal contract with BCBS IL. NOT the generic one. If you have to leave a message, do so just asking her to return your call. You don't have to say why you are calling in the message. If she doesn't, then find out who is her boss and talk to that person, keep going up the food chain.

 

[irishmom1972]

Irishmom, perhaps your height needs to be rechecked. You are so close to 50 that a half inch could make a difference.

DBmom23, thanks so much. I've been trying to figure out how I can get my height rechecked. It's hard to be off/less by 2 inches though. I think that would put me at 50.

 

[irishmom1972]

Call her yourself. Tell her you need a copy of the document they give to employees every year that spells out THEIR personal contract with BCBS IL. NOT the generic one. If you have to leave a message, do so just asking her to return your call. You don't have to say why you are calling in the message. If she doesn't, then find out who is her boss and talk to that person, keep going up the food chain.

Thanks so much. He forwarded me the emails when asking his HR lady for the EOC for me. The small engineering firm that he works at uses a third party Benefits Administrator to manage their insurance plan. Never heard of this before. The HR Manager at my husband's company that I was trying to reach yesterday asked the third party Benefit's Administrator company if they had the EOC. No one knows what the heck I'm talking about. My husband wrote the Third Party/Benefit's Administrator and said he needs a EOC, Evidence of Coverage, for Bariatric Surgery, specifically for the Biliopancreatic Diversion with Duodenal Switch. This is what the Third Company replied:

From: Lupe Salgado
Sent: Monday, October 12, 2015 1:15 PM
To: Luke Barnett
Subject: RE: BCBSIL Evidence of Coverage




Best way would be for the provider to do a pre-certification using medical policy # and diagnosis codes. Unfortunately, many times Doctors will have members call their insurance to see if a procedure would be covered without a lot of information. I did a quick search of the Medical Policy for the procedure listed below and the result came up as Bariatric Surgery – see attached Medical Policy on this type of service. This is available via the BC BS Provider portal and it is in the main domain for anyone to access.




The SBC specifically states that Bariatric Surgery is a covered procedure (page 5 of the attached SBC), however, before BC BS would determine if it will be covered, the provider would have to verify the Diagnosis and provide all the necessary documentation that would allow BC BS to make a determination if the surgery would be covered. Therefore, it is not a simple YES or NO answer.




Hope this helps.




Lupé Salgado


Office: 630-810-9100 x 134


Direct: 630-737-9350


Supposedly my husband has requested more specific information and it's forthcoming. However, I'm not confident that when I do call this third party Benefits Administrator and the HR lady at my husband's company that they will know what I'm talking about.

 

[Larra]

Like @southernlady said, keep on calling and keep moving up the food chain if these people don't know what an EOC is. There is such a document for every policy. You need to read the specifics not just for bariatric surgery in general but for the DS in particular, AND you need to know what your appeals rights are if you get a denial. So the document in question is NOT just a page or 2 about bariatric surgery, it's a huge document, like maybe 100 pages, covering everything your policy covers. And yes, you are entitled to it, either on paper or online. Keep on trying. Call every day, ask to speak with a supervisor, whatever it takes to get that document.
If you do end up with a denial, which seems likely at this point, we can help you to fight that denial ONLY IF you have appeals rights, which we don't know at this point, and ONLY if we know the details of your policy and of course the reason(s) given for the denial. We don't need to worry yet about reason(s) for the denial because that hasn't happened yet, but you really are lost in the woods without your EOC.