Final Denial- All internal appeals have been exhausted (the meaning of "non-compliant")

Trilla

Member
Prior to this, I was denied for being "non compliant" with no explanation as to what that meant, also that i didn't have a BMI of 50 (my weight fluctuates- when i was weighed, I was 6 lbs (SIX!) under 50 BMI; but I have documentation that I am over 50 BMI too) . I called 3 times and was rebuffed each time saying my doctor was the only one who could find this out. My doctor was not told either. I received this "final denial" letter finally explaining what "non compliant" meant. It was that my doctor's "notes didnt show that I tried a diet and exercise program" I gave my doctor 2 pages of things that outlined my support system, my history, all the things i tried, etc., but he only included what I listed as having for a support system. I attached one page of the denial.

I was rather distraught, especially since I received this final denial on the 1 year anniversary of my daughter's death. Now I am back to try to write up my case for this surgery.

According to BCBSIL I can request an External Review by an Independent Review Organization (IRO). It states that I can "request copies of all documents relevant to the appeal including the specific treatment and diagnosis code(s) and any new or additional evidence not utilized during prior reviews."

I will be calling the appeals specialist tomorrow to get whatever I can get. I wonder what evidence they didn't use before.... anyway... The form they provided seems to be quite useless (i've attached it). It only gives a few lines to state why i think the decision was not correct. I called Accolade (the third party vendor they use so the insured can't speak to anyone in BCBSIL) and said i was going to request an external review. I was trying to get help to figure out what I should provide.

She was also useless. she repeated i should just fill out the form and when i wouldnt let it go by saying, look you are supposed to help me, should i provide a letter from my doctor? a list of everything that i have tried? what? I think i pushed her because she went off about just send them everything and anything you think will help. letters from every doctor, any proof of diets, proof of exercise, proof of anything you think might help....

I went to the internet looking for what I should do to convince people that i need this surgery. I found the following and i noted in red where I need your help
  • A letter from your doctor explaining why the requested treatment should be approved
    • I am going to email my general physician, my therapist, and my orthopedic surgeon asking them to write this
    • I need to tell them what they need to write, what points to hit to be the most effective. As many of them have never written a letter for their patient to get this surgery.
    • I attached the letter Dr. Ayoola sent to BCBSIL for the last appeal that resulted in the final denial
    • I attached the report from the doctor who did an endoscopy and said that my stoma and pouch were much larger than expected
    • Does anyone have an example? or what i should tell them to include?
  • Patient notes from your treating physician on other care you have had for your condition
    • I'm not 100% sure what this means.
  • The results of other tests or procedures related to the request
    • I'm not 100% sure what this means either
    • I had RNY in 2005, i have sleep apnea, high cholesterol, arthritis, depression
    • isn't this the same as the previous one?
  • Current medical articles or study results that support the treatment’s effectiveness
    • I found the following articles. I included reference information as well as a quote stating the conclusion.
    • Do I need to include a copy of the articles or is referencing and a quote enough?
    • Are their anymore for conversion from a RNY to DS?
    • They are stuck on this arbitrary 50 BMI... is there any research that number is total BS?
      • Conversion of failed roux-en-y gastric bypass to biliopancreatic diversion with duodenal switch
      • Outcomes following laparoscopic conversion of roux-en-y gastric bypass to biliopancreatic diversion with duodenal switch
      • Biliopancreatic diversion with duodenal switch. Long term weight loss
      • Laparoscopic conversion of failed gastric bypass to duodenal switch
      • Duodenal switch provides superior weight loss in the super-obese (bmi > or =50 kg/m2) compared with gastric bypass
  • Your own letter explaining why you believe the treatment is needed
    • I will provide this letter to you all for feedback when I'm done the first draft.
    • If someone could share an example of one that actually worked, that would be awesome
Is this good? what else has worked?

anyone out there that has gone through an External Review by an Independent Review Organization (IRO)?

The other thing i don't trust is that im mailing all this stuff to BCBSIL.... are they going to decide whether or not my request is allowed to go to the external review IRO? I mean, can't they just not send it? and just write me saying that it wasn't accepted by the IRO and its still denied? I mean, how would i know. Is the IRO really impartial or are they working for BCBSIL?

Lots of questions and help requested. Does anyone have the time to go through this and answer each of my concerns?

Thank you in advance
 

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hilary1617

First time at the rodeo.
Trilla ,

First, I am sorry for the loss of your child. My heart goes out to you.

I was initially denied for a virgin DS by BCBS IL in 2010 in essence for the same reason. Mainly I came to understand that their rationale was that the doctor had not sufficiently documented the 6 months diet/exercise counseling, even though at time of submission I had evidence of the immediate past year of (weekly receipts of mail-order) a 1200 calorie prepacked food plan, multiple visits to my primary GP during that period with weight recorded and some weight loss and counseling by my primary physician evidenced in physicians notes, which also referenced of years of our discussions of prior diets/counseling/personal trainers including programs such as nutrisystem and Jenny Craig, etc. It was SO FRUSTRATING. So I can relate to how you must be feeling.

I was not dissuaded. I persisted and just lengthened the prep timeline. As BCBS IL had said that my denial was based on lack of evidence of physician supervision of compliance and physican counseling, I knew I had to demonstrate in writing routine, periodic, frequent counseling from a licensed physician in order to get DS.
I ended up going to a local "diet doctor" and signing on to a liquid 900 calorie diet plan with weekly physician visits. The liquid diet was supposed to be administered for 6 weeks only, but I kept on it for almost a year and a half. Overkill, I know, but I'm a "go big or go home" type. The diet and weekly physician's notes provided the evidence necessary and the second time I applied, I was approved immediately.

As to BMI, at the time, there was a lower limit if there were comorbidities present, like sleep apnea, diabetes, heart issues, etc. Does this still exist? Have you been tested for every possible qualifying cormorbid?

Best wishes and hang in there. It is worth it. You are worth it!
 
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Sheanie

Well-Known Member
So sorry for the loss of your daughter.

Cheers for your courage and strength to continue this fight.

Throw EVERYTHING at them. Diet drugs, OTC and Rx that you've tried. Diet groups, WW, etc.

Noncompliance is an insulting term. You have every right to be mad as hell. USE THAT anger.

Call them back, ask "what are the CRITERIA that must be met to overturn their decision." Ask what comorbidities you need.

All your comormidities seem to have returned with RNY. This is significant. In addition, try to get ANY WLS covered. If they approve anything, it should be easier to switch to DS.

Arent you working with Diana Cox and Larra?
 

Trilla

Member
Thank you ladies. I mourn everyday. I am trying to focus my energy on something else to help me through.

I am not working with them.

DianaCox and Larra how do i start working with you to help me be successful?
 

Larra

Well-Known Member
Trilla, you were almost guaranteed to get a denial from your insurer because they have nothing to lose by denying, and they could use any excuse they could come up with, or no excuse at all. It costs them nothing to deny, and they can hope that, like many others, you will give up, or change insurers, or just disappear. So good for you for not giving up.
It's very important at this point to be both thorough and well organized. I would recommend you start a private conversation with both me and DianaCox so we can exchange emails and stay on the same page with you, and review letters, documents, etc with you. Please include BOTH of us - it doesn't work well if we can't all communicate together. And, if you don't already have it, get your EOC (evidence of coverage, which is a lengthy document that spells out all the details or your coverage), all medical records, and in your case the evidence that there is something amiss with your old RNY (this may be key, IDK at this point) and also any documentation in your medical records from any provider with your highest weight/bmi.
 
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