MINMAN61
Member
- Joined
- Sep 24, 2018
- Messages
- 5
This was also posted in the Say Hello thread but a friend in the DS PEople in the USA Told me to post it here too.
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
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
