Amey
Well-Known Member
- Joined
- Jul 15, 2015
- Messages
- 230
I need to vent/rant/invite you all to my pitty party for a minute...or two. I just need some support... Someone to tell me this will all be worth it... Everything will be ok and it will all be worth it. I need to see it in black and white. Because nobody else in my family or friends will truly understand except you all here. And I apologize in advance because this may get long.
I am currently sitting on my couch eating cottage cheese and mandarin oranges and drinking a protein shake as part of the liver shrinking diet my doctor requires.... Honestly it's pretty generous as liver shrinking diets go... And I'm not complaining about being hungry or what I can or can't eat... Not one bit.
I am scheduled for DS surgery on the 28th.
My insurance company, Blue Cross of Idaho, is creating a nightmare of a dark and ever-changing rat maze where they keep moving the cheese and reaaranging the walls. I am exhausted, tired, and discouraged. Some days I feel like a fighting lioness... Other days I feel like I'm looking for water in the Serengeti.
My insurance policy has an exclusion for bariatric surgery.. But also has an exception to the exclusion that says 'As a medical necessity for a covered medical condition that is not controlled by other non surgical means'. I have a BMI of 50 and have Severe Obstructive Sleep Apnea... And I'm allergic to the silicone in the masks so i can't use it enough to be therapeutic. My Cpap doctor has written a letter stating that it is not controlled due to my allergy.
I have submitted for DS surgery with 2 seperate surgeons out of state and the current one that is in-state but relatively new to DS... Ok so she has never really done a full DS on her own... But has her proctor, Dr Fred Bonani, from PA coming in to proctor a week of DS surgeries so that she can do them on her own. I would really feel better if I was in the group with the experienced Dr Bonani present... Call me crazy....
The insurance coordinator at my current surgeon's office told me that she had never seen BC deny anyone for bariatric surgery that even vaguely met the exclusion... Even with just 'ankle pain'. Granted... These were all sleeves and a few RNYs. The practice has never done DS before so there is no DS history to go by with that. I personally know 3 people who have the exact same private 'health care exchange' BC policy I have and have been approved for sleeves... 1 was just this week. Other patients scheduled that week for DS are either private pay, have Medicaid, or Medicare. Nobody with my 'health care exchange' plan has tried to be approved.
Getting to the point..... I am waiting for a decision on my appeal submitted on the 5th. I wrote an 8 page letter with attached documentation totally 20 pages. I was never given an exact reason why I was denied so I tried to hit every possible reason I could think of for my policy. I had help from @DianaCox and @Larra, who are honestly true angels, and without them I would not have even known where to start. I called Blue Cross on Tuesday to get a status of my appeal. This guy in Appeals and Grievances coordinating my appeal said that they had sent my appeal 'out' to an INTERNIST because they do not have a like or same doctor on staff that would be qualified to make the decision. Ummm an INTERNIST... Really?? (see below regarding HIPAA request .... But I was also told that I was not allowed to know the internist's name or credentials, because it's 'confidential' - this violates my HIPAA rights) So... The internist's letter says... According to the BC guy.... That he agreed with the denial because I had not tried 'all other options' to control my sleep apnea and that there is no research or studies to prove bariatric surgery cures sleep apnea. Let me just say what we are all thinking... He's a idiot!! I may have said something like... So does that mean I need to go to Brazil and eat beetles and poor lizard piss down my throat while standing on my head and a witch doctor shakes feathers and dances around me.... Just to make sure I have 'tried' everything else. He didn't appreciate my sarcasm. However.... I also reminded him that cpap therapy is the best medically accepted treatment for Severe Obstructive Sleep Apnea.... And the nasal spray, dental devices, nose strips, and extra pillows at night that the 'internist' is suggesting might help mild or moderate apnea but I have SEVERE apnea and even my doctor says those things are worthless.
Blue Cross guy tells me that he would fax the denial letter to me that day. Of course he didn't. The next day he tells me that he has to write a letter to go with the internist's letter and he is recommending that the denial be upheld BUT he tells me that he only makes the recommendation.... That 'medical review' makes the final decision. The next day nobody would take my call or return my voice messages. Thursday I got mad and demanded to talk to his boss.... Then I had to ask to speak to his boss because nobody would talk to me. At one point I was transferred to security. I needed to get the denial letter so that I could start on an external appeal. Then.... I was told and verified by 3 people that my appeal was still 'in review' and had not been adjudicated yet. What?!?
Side note.... At the same time I filed my appeal I also filed a complaint with the Idaho Dept of Insurance. I have been assigned a rep that actually returns calls and emails and has started an inquiry as to why my doctor was denied a peer to peer review and a provider appeal and why my original request was denied by a 'customer service rep' with no medical background and why they approve other members with less qualifications and are denying my request (most likely because I'm requesting a DS and they got sleeves, however DS is a covered procedure for members meeting the criteria of the exclusion). The Idaho Dept of Insurance rep says that my documentation shows I meet the exclusion in spades. However, in an External Appeal she would not be making the decision.. It would go to an outside agency unaffiliated with Blue Cross but contracted by the Dept of Insurance.
I have also fully taken advantage of the Privacy and Security rule of the HIPAA law in a 4 page letter to Blue Cross. I have requested, in writing, the names and job titles and medical qualifications of all employees that could or did have access to my records, how they determine who is allowed access, their training material, proof that the employees with access or could have access to my data have received HIPAA training and how often the training is refreshed. I have also requested all copies of my records in the following forms... electronic, written, and transcripts of verbal communication via phone - recorded for quality control
- or otherwise that may pertain to me or my medical data or personal information and appeal. They have until February 5th to provide all the information. The penalty to deny that information is $50,000 (to the government.. Not to me...dang it). But I'm hoping this will put a little pressure on them to do the right thing and approve my appeal to get me off their backs. Maybe it doesn't work that way but a girl can hope.
Back to my appeal, the inquiry of the Dept of Insurance, and my HIPAA request. Blue Cross has until the 19th to deliver a decision on my appeal... That's Tuesday. That is also the same date they are required to answer the inquiry by the Dept of Insurance.
My surgeon is holding my space for me on the 28th. Doing the math here.... 2 week liver shrinking diet should have started the 14th. I didn't start until the 15th (yesterday) because I thought my appeal had been denied and didn't think I had a chance in hell). I'll do a day of clear liquids to make up for it (I'm hoping that will be ok) So I'm doing the liver shrinking diet and don't even know if I'll be able to have surgery.
I'm praying, crying, burning candles, and making deals with God.
Hoping for the best... Preparing for the worst. Knowing that i could be doing this liver shrinking diet for nothing...... That the hundreds of dollars in vitamins I have bought and taken religiously the past 4 months could have all been a worthless attempt to prepare for a life-saving surgery that may never happen.
But....
Today.... I have HOPE... And I have all of you. Today I am not giving up. Today I am still fighting. Today I choose to be the lioness...and I'm going to eat my cottage cheese and 4 cups of vegetables like they are a meal for a queen.
If you made it this far thanks for listening to my rant.... And if you so believe.... Please send a prayer or a positive thought into the universe for me. And thank you all for keeping me going!!
I am currently sitting on my couch eating cottage cheese and mandarin oranges and drinking a protein shake as part of the liver shrinking diet my doctor requires.... Honestly it's pretty generous as liver shrinking diets go... And I'm not complaining about being hungry or what I can or can't eat... Not one bit.
I am scheduled for DS surgery on the 28th.
My insurance company, Blue Cross of Idaho, is creating a nightmare of a dark and ever-changing rat maze where they keep moving the cheese and reaaranging the walls. I am exhausted, tired, and discouraged. Some days I feel like a fighting lioness... Other days I feel like I'm looking for water in the Serengeti.
My insurance policy has an exclusion for bariatric surgery.. But also has an exception to the exclusion that says 'As a medical necessity for a covered medical condition that is not controlled by other non surgical means'. I have a BMI of 50 and have Severe Obstructive Sleep Apnea... And I'm allergic to the silicone in the masks so i can't use it enough to be therapeutic. My Cpap doctor has written a letter stating that it is not controlled due to my allergy.
I have submitted for DS surgery with 2 seperate surgeons out of state and the current one that is in-state but relatively new to DS... Ok so she has never really done a full DS on her own... But has her proctor, Dr Fred Bonani, from PA coming in to proctor a week of DS surgeries so that she can do them on her own. I would really feel better if I was in the group with the experienced Dr Bonani present... Call me crazy....
The insurance coordinator at my current surgeon's office told me that she had never seen BC deny anyone for bariatric surgery that even vaguely met the exclusion... Even with just 'ankle pain'. Granted... These were all sleeves and a few RNYs. The practice has never done DS before so there is no DS history to go by with that. I personally know 3 people who have the exact same private 'health care exchange' BC policy I have and have been approved for sleeves... 1 was just this week. Other patients scheduled that week for DS are either private pay, have Medicaid, or Medicare. Nobody with my 'health care exchange' plan has tried to be approved.
Getting to the point..... I am waiting for a decision on my appeal submitted on the 5th. I wrote an 8 page letter with attached documentation totally 20 pages. I was never given an exact reason why I was denied so I tried to hit every possible reason I could think of for my policy. I had help from @DianaCox and @Larra, who are honestly true angels, and without them I would not have even known where to start. I called Blue Cross on Tuesday to get a status of my appeal. This guy in Appeals and Grievances coordinating my appeal said that they had sent my appeal 'out' to an INTERNIST because they do not have a like or same doctor on staff that would be qualified to make the decision. Ummm an INTERNIST... Really?? (see below regarding HIPAA request .... But I was also told that I was not allowed to know the internist's name or credentials, because it's 'confidential' - this violates my HIPAA rights) So... The internist's letter says... According to the BC guy.... That he agreed with the denial because I had not tried 'all other options' to control my sleep apnea and that there is no research or studies to prove bariatric surgery cures sleep apnea. Let me just say what we are all thinking... He's a idiot!! I may have said something like... So does that mean I need to go to Brazil and eat beetles and poor lizard piss down my throat while standing on my head and a witch doctor shakes feathers and dances around me.... Just to make sure I have 'tried' everything else. He didn't appreciate my sarcasm. However.... I also reminded him that cpap therapy is the best medically accepted treatment for Severe Obstructive Sleep Apnea.... And the nasal spray, dental devices, nose strips, and extra pillows at night that the 'internist' is suggesting might help mild or moderate apnea but I have SEVERE apnea and even my doctor says those things are worthless.
Blue Cross guy tells me that he would fax the denial letter to me that day. Of course he didn't. The next day he tells me that he has to write a letter to go with the internist's letter and he is recommending that the denial be upheld BUT he tells me that he only makes the recommendation.... That 'medical review' makes the final decision. The next day nobody would take my call or return my voice messages. Thursday I got mad and demanded to talk to his boss.... Then I had to ask to speak to his boss because nobody would talk to me. At one point I was transferred to security. I needed to get the denial letter so that I could start on an external appeal. Then.... I was told and verified by 3 people that my appeal was still 'in review' and had not been adjudicated yet. What?!?
Side note.... At the same time I filed my appeal I also filed a complaint with the Idaho Dept of Insurance. I have been assigned a rep that actually returns calls and emails and has started an inquiry as to why my doctor was denied a peer to peer review and a provider appeal and why my original request was denied by a 'customer service rep' with no medical background and why they approve other members with less qualifications and are denying my request (most likely because I'm requesting a DS and they got sleeves, however DS is a covered procedure for members meeting the criteria of the exclusion). The Idaho Dept of Insurance rep says that my documentation shows I meet the exclusion in spades. However, in an External Appeal she would not be making the decision.. It would go to an outside agency unaffiliated with Blue Cross but contracted by the Dept of Insurance.
I have also fully taken advantage of the Privacy and Security rule of the HIPAA law in a 4 page letter to Blue Cross. I have requested, in writing, the names and job titles and medical qualifications of all employees that could or did have access to my records, how they determine who is allowed access, their training material, proof that the employees with access or could have access to my data have received HIPAA training and how often the training is refreshed. I have also requested all copies of my records in the following forms... electronic, written, and transcripts of verbal communication via phone - recorded for quality control
- or otherwise that may pertain to me or my medical data or personal information and appeal. They have until February 5th to provide all the information. The penalty to deny that information is $50,000 (to the government.. Not to me...dang it). But I'm hoping this will put a little pressure on them to do the right thing and approve my appeal to get me off their backs. Maybe it doesn't work that way but a girl can hope. Back to my appeal, the inquiry of the Dept of Insurance, and my HIPAA request. Blue Cross has until the 19th to deliver a decision on my appeal... That's Tuesday. That is also the same date they are required to answer the inquiry by the Dept of Insurance.
My surgeon is holding my space for me on the 28th. Doing the math here.... 2 week liver shrinking diet should have started the 14th. I didn't start until the 15th (yesterday) because I thought my appeal had been denied and didn't think I had a chance in hell). I'll do a day of clear liquids to make up for it (I'm hoping that will be ok) So I'm doing the liver shrinking diet and don't even know if I'll be able to have surgery.
I'm praying, crying, burning candles, and making deals with God.
Hoping for the best... Preparing for the worst. Knowing that i could be doing this liver shrinking diet for nothing...... That the hundreds of dollars in vitamins I have bought and taken religiously the past 4 months could have all been a worthless attempt to prepare for a life-saving surgery that may never happen.
But....
Today.... I have HOPE... And I have all of you. Today I am not giving up. Today I am still fighting. Today I choose to be the lioness...and I'm going to eat my cottage cheese and 4 cups of vegetables like they are a meal for a queen.
If you made it this far thanks for listening to my rant.... And if you so believe.... Please send a prayer or a positive thought into the universe for me. And thank you all for keeping me going!!
