DS 2nd Part Denied by BCBS of IL

[MINMAN61]

Hi All,

I was told to come here and reach out for some assistance.
On Dec 11th 2017 I went in for a DS. At the time of surgery I weighed 407lbs.
I had gone down from 439lbs on my preop diet of 7weeks.
I had my surgery by Grand Health Partners Dr. Kemmeter.
He went to do a DS but was not able to complete it ( I was approved for a DS by BCBS of IL)
His reason for not completing was my abdomen was 4" thick and I had a net put in behind my navel back in 2001 those two things made it unsafe to do the re-route of the intestines at the time of the surgery....so he gave me a sleeve and said we would finish the surgery in 7-8months.
So now fast forward to getting the approval for the 2nd phase of the DS...this is not two bariatric surgeries this was ONE Surgery done in two parts to do medically being unsafe to do as a laparoscopic surgery and my surgeon only does an open if I were bleeding out and he would open me to save my life period.

So now Blue Cross Blue Shield of IL has denied my 2nd stage.
Calling it unlisted, non essential, and not a proven surgery. and 30pages of stuff. (they already approved it prior to Dec 11th 2017)
They came back and required me to see the psych doctor again since I had not seen on since 2017.
So I did that and she agreed this was the best surgery for someone with a starting BMI of over 70 and I had lost 140lbs with both preop and postop loss at 8months out.
So we submitted their requests and they denied it based on the reasons I listed above.
My surgeon filed for an appeal and a peer to peer review.
That was done and the doctor he talked to on the phone in the peer to peer told him he was not qualified to overturn this denial on the phone but he would get with someone higher up to see if he could get it overturned. They asked that he FAX this info to him since my surgery is supposed to be October 15th an they wanted it to be on the fast track.

So I waited a day and I called and talked to an agent who said that's highly unusual that he was not able to do that right on the phone and she commented that she used to work in that dept as well. That this doctor 19mins after the call did not do what he said he was going to do and he went in and closed my case and marked it unable to overturn the appeal...but he never notified my surgeon.
She said at this point that I needed to do a fax and send in an URGENT MEMBER APPEAL and it would fast track it to be reviewed. I did that last Thursday and now I called today and my surgeon has never gotten a denial fax and the agent I talked to today told me my appeal is only an URGENT appeal if i am dying. So it would take 30-60 days for review. And I said that I had requested they overturn the denial on the grounds that this surgery was already approved once and their listeing it as unlisted and non essential and non proven was not valid if they had already approved a DS before. Also listed why the same way the surgeon did...and I was told that doesn't matter.

My surgeon is waiting for an actual fax or denial by fax to show them so they can file for another clinical review appeal to go with my urgent member appeal my personal appeal. The agent on the phone was saying the case is OPEN in the records but it would take 30-60 days for review since its not urgent.

My surgery is penciled in for Oct 15th and I need this to happen before the weather gets back in Michigan I live 2hrs from Grand Rapids where this is going to happen. Also its peak season at my job and this has caused a lot of negativity and stress in my job from co-workers. And emotionally as well. This should never have been denied its not a revision its a TWO PART Surgery due to medical necessity. Which was VERY well explained to them on 3 occasions This 2nd authorization process all started back in June its now almost Oct and I am being denied.

I was told to contact Larra and/or Diana here. PLEASE HELP!
I have the surgery documents and the denial from the initial denial this past time before the peer to peer..but we have been given nothing since the peer to peer! I don't want to upload private medical data here because this is a public thread right? Anyway I have all kinds of PI in it and this is not where I feel comfortable puting it.

Michael Inman

 

[DianaCox]

Start a conversation with Larra and me.

 

[k9ophile]

I can't help you. However, I want to wish you success. Diana and Larra are the best. I'm tempted today if they can't help you, no one can, but I don't know that is true. I just know that their record of helping people is phenomenal.

 

[hilary1617]

Hi and welcome MINMAN61 . I hope that you are able to get the appropriate authorization in a timely manner. All the best!

 

[MINMAN61]

Start a conversation with Larra and me.

Hi Diana and Laura

Have you read my post in Say hello? I was told by a person in the Duodenal Switch in the USA Facebook group to post and talk to you both. That if anyone in this world could help me it would be both of you that you were the best! So here I am!

 

[southernlady]

Hi Diana and Laura

Have you read my post in Say hello? I was told by a person in the Duodenal Switch in the USA Facebook group to post and talk to you both. That if anyone in this world could help me it would be both of you that you were the best! So here I am!

If you don’t know how to start a conversation:
Click on Diana’s picture of herself. An overlay will pop up and one option is to start a conversation. Click it and add Larra to the top next to Diana’s name.

If you get lost doing that, post here and I’ll start it for you and then bow out.

 

[DianaCox]

Your surgeon needs to contact the insurance company and strenuously object to the denial on the basis that you previously had approval for a full DS, and that the surgery was not completed due to unexpected complications during the procedure that made it unsafe to complete the surgery at the time.

 

[MINMAN61]

Hi Diana,

He has had a peer to peer review with a medical doctor at BCBS of IL. The dr. he talked to told him he could not overturn the denial himself but he would get with someone higher up who may be able to. Then 19mins after the call he closed my case. The Surgeon has never even gotten a denail i found out by calling myself that a "the denial was upheld" by the doc he talked to. so I Should call my surgeon's office tomorrow request he talk to me. Tell him to call the insurance company to stenuously object to the denial being upheld on the basis that they previously approved it but the surgery was not completed due to unexpected complications during the procedure that made it unsafe to complete the surgery at the time of the original operation?

I have tried to get through his surgery schedulers requesting they have him call me but they seem to be his gatekeepers here. They are going down a path that is going to make this current date of Oct 15th not happen so he needs to expedite his objection call them and demand they overturn the denial based on those grounds?

Thanks for your help so far!

Mike

 

[DianaCox]

I hate to tell you this, but the October date is not likely to happen. You’re going to have to file an appeal. You need to get the denial in writing, which should include a description of your appeal process. Larra and I will help you through it. You will need a strong letter of medical necessity from your surgeon explaining in detail why this is not a revision but rather a completion of a previously approved surgery.

 

[MINMAN61]

I have the denial in writing from them the original denial. Then my surgeon requested a Peer to Peer review.
He did that last week on Thursday. Was told by the MD that he talked to that he was not of a high enough level to overturn the denial but he would get with someone and let him know. My surgeon asked to get a FAX back rather than a letter in the mail with this decision. He never got one. I called and found out that the MD he talked to in the peer to Peer closed the case with denial upheld 19mins after he talked to my surgeon. The agent I talked to told me to file an URGENT MEMBER APPEAL and fax it in...they have it but are saying its not urgent unless i am dying. ( did you catch all that from my past posts? Just wanting to make sure you know I have already filed an appeal but was told it would take 30-60 days for them to review it.)

So should my surgeon's office call them or have him call them and do what you said in your last message?
Oh and my surgeon already sent a letter explaining this way back when this all first started before the denail....then they denied it and then he asked for a peer to peer and then they never told him but I discovered when I called in to check that the denial was UPHELD after that so the agent told me to write that appeal and fax it in and I did. This is crazy I was approved for a full DS as you know. Now they are denying it. But from what I read in here BCBS of IL seems notorious for this.

 

[DianaCox]

Oops - I wrote this last night and forgot to post it:

We need to see what was said in the following documents:

• Your surgeon's request for preauthorization
• The denial letter, including the disclosure regarding appeal rights and procedures
• Your appeal letter
• Any notes regarding the Peer-to-Peer, including documents related to the decision

Start a conversation with Larra and me so we can send you our email addys, so you can send us the documents.