Regence BC/BS idaho denied on revision

[shiftedsanity]

Hello All,
I am new here and was hoping to find some advise on revision denial due to "investigation". I was also told that I would have to do a six month 'managed weight loss program".
I posted some of my history on another board.
www.duodenalswitch.com/forum/showthread.php?t=9783
If anyone can help with information, I would apreciate it.
Highest BMI 83.4 565
April 2013 BMI 59 400
June 29 BMI 56 380
Goal? Not to die from obesity
Thank You All.
I am looking forward to learning more and hopefully appling the knowledge.

[shiftedsanity]

Thank you for your reply.
I went back to my PCP and informed her of what I was going through. She is contacting the HR dept. this week. There is an extreme amount of pressure on me to get this resolved by HR. I have informed them that I was advised to pursue WLS by my PCP and was taking steps toward that goal. I asked them if they could help expedite the process to no avail. So I am hoping the PCP will have better results.
I have started to collect information to support an appeal in case this does not help.
My surgeon had a peer to peer with Regence and it was still denied. The criteria first expressed by Regence to the surgery centers patient coordinator was not in fact correct and at this point the surgeon is in a holding pattern until I work through the pre-op demands of the insurance.
All of the other WLS costs have been out of my pocket. I do not know how that plays, (with Regence) as far as the second stage is concerned.
I find all this mentally frustrating. I hope I have good news from the PCP this week.

[Deleted]

Diana is right (of course), this is a continuity of care issue. In my opinion, for the insurance company to require a 6 month diet is unsupportable. This is not a virgin surgery. Is the 6 month diet requirement something that someone from the doctor's office told you or have you received that wording in writing from the insurance company?

What do you have in writing from the insurance company? If you have been denied, what was the exact wording in the denial? When was the denial? When is insurance enrollment for your company? Do you have a copy of your insurance plan summary and the specific wording for any criteria for bariatric surgery? Has the only appeal so far been that the surgeon picked up the phone to call the insurance company?

The PCP may not have the resources available to handle the appeal process for you. That might be up to you (that's pretty common). They might write you a great letter of medical necessity and help you gather documentation, though.

If you don't have it already, you need to know what the appeal process is for your insurance plan. This may have come in writing with a denial letter. You may need to get started right away on an appeal. Time is of the essence.

I hope you go after this. Hard. While you are waiting, you might even want to consider asking for a couple of second opinions from surgeons.

I think you can pull this off if you really want it, but they are going to make you fight. It can be done and I believe that you can pull this off if you really want it. Good luck to you. Your quality of life is worth fighting for. I hope that this is helpful and encouraging to you.

[shiftedsanity]

Thanks for your reply protiensnob...it is an on going battle and I am not looking forward to the stress it will present. This is an abridged version of the events I have been through so far.


1st...I was a instructed by HR to find a PCP that would provide health care focusing on weight management. That I must show steady progress in reaching a weight below 350 pounds and maintaining my weight below it. If I could or would not comply they would fire me. I then had to sign paperwork agreeing to this to go back to work.
2nd.....I found a wonderful Doctor that understands obesity and the ongoing struggle it presents. She advised me to seek a WLS Surgeon and pursue a RNY type surgery.
3rd....called Dr. Srikanth in Federal way for consultation. The Patient coordinator checked my Insurance. I was told by her that the information she received would allow for surgery with no waiting period. I would have to get my testing completed. ...I saw the Surgeon
4th....he scoped me to determine the damage the eroded band had done. He then advised me of options and suggested DS would be the best choice considering the scarring. We were confident at that time, insurance was not an issue and set up a date. I tested. I started preoperative dieting. He submitted for pre approval. The insurance deadline surgery date were right on top themselves. So believing what we were originally informed, I traveled 5 hours to the center only to be denied for surgery. I was literally waiting 100 yards from pre op when Regence got back the Surgeon with the final decision. This was for two reason's. I had not met the 6 month pre dietary criteria and the D S was considered investigational.
5th.....I went back to my PCP. She felt the next step was to contact my HR Department and explain how the scarring in my upper stomach may exclude the RNY as the best option for success. How the DS was recommended by my Surgeon and the proven history of it and other DS related facts.

this is where I am at right now. HR has the ability to make insurance allow an exception to the policy considering the situation.
I am in my 3rd month pre diet at this time. I am collecting information on the DS to pursue an appeal if I must. I am looking into what info I need as well when I am post op. Also finding inspiration from the many in here that have been fighting with the same monster I fight. I have a four appeal process. I do hope it doesn't get that far considering the pressure I have from my Human Resources Department.
So thanks again for helping me herd all these cat's or so it feels like. I will post when i know more.

[shiftedsanity]

Diana thank you so much for the positive support. I contacted my PCP and they got nowhere with HR. They were told to go through the appeal process until that was exhausted and then it was upon them. I was extremely disapointed when I was informed this. I politely offered to take it to an advocate (such as Kelly and Walter Lindstrom knowing it would be close to a grand gamble) and they said they wanted to take this on. I really do not look forward to the stress waiting to mount an appeal without an expert. But I do respect the passion and the knowledge of my primary care Doctor. She and her husband who is the office manager are working their butts off for me. I will compile as much information as possible in hopes it will aid them as my representatives.

I am not sure if a Doctor in mexico has as much inpact with her recommendation to DS in two stages. That coupled with the greed of BC/BS. Makes me believe I am in an uphill battle. I honestly think the feeling i get from my HR ,choice not disease, will demand a cage match for coverage.

[Deleted]

Diana, you rock.

SS- I think I understand what you are saying and that people are trying to help you, but Diana is right. She knows her subject matter very, very well.

You can go through the appeal process while all of those people advocating for you. Hit the insurance company on several fronts at once. BTW, the Lindstroms are not even close to a grand unless you want expedited help. I know because I just used them. Threatening to use attorneys doesn't do much good. If you start burying them in paperwork, calmly and thoroughly going through the appeals process, and then letters from attorneys start showing up or even if attorneys start getting copied- this is when people realize that they will need to honor their contracts and follow laws.

Don't worry about where the first surgery was done. The point is that is was done. Do not stress out about things that are not specifically brought up in the denial letter by the insurance company. They may never even come up. Focus on attacking exactly what is in the denial letter with your appeal.

The appeal letter packet might sound really intimidating, but it's not. Diana just gave you gold references up there. You can find generic appeal letters everywhere if you don't know how to write one. Or post your draft (with personal info deleted) here and maybe you'll get some good feedback.

Unless someone is writing your appeal letter in the next two days, get fired up and get it done. If you don't do this yourself, you are right about this being an uphill battle. Follow what your insurance plan summary says to do for appealing a denial. Not many follow through and do that, and it scares the cr*p out of insurance companies.

You can do this.

[shiftedsanity]

Much thanks to both you and Diana. Big ups for the "you rock" as well. I am not great at paper work, but I will be working at an appeal letter addressing the issues stated in the denial. Its hard to think that if my surgeon could not persuade the insurance, I could.
I was not threatening with lawyers, in fact, I was told they were only representatives through the full process. I talked to Kelly last week. ..she was terrific. The package or level of help I was considering was 950.
I will be drafting an appeal for you guys to critique. ..be pre warned...this is not my strong suit. ...any help is appreciated ...I will muck my way through it one way or another
again many thanks to you and Diana for your input

[shiftedsanity]

I have just started my battle. DianaCox and protiensnob have good knowledge. I was shooting for completing my appeal letter this week end but did mot realize the time frame for records to arrive. I spent two hours with Customer. Service today just to guarantee they were sending the full file. I also wanted to be sure they reviewed the calls from my Surgeon.
This is why
I called to get the Cust. Ser. Today to read the exact wording of the exclusion. I was informed my policy excluded WLS all together. UMM WHAT
SO I CALLBACK
EXPRESSED my concern for poor representation. ..When the Surgeons PC started to check my coverage she was misled..._______ me once...shame on you....
twice?

I explained how it led to costing time money and a week of vaykay....very nice Rep made sure this call was thoroughly handled properly......and even by expediting my info...I would still be a week out.....so start them coming now.....the best info you will get will be best served from the Royals in here and the many that won their battle.

Best of luck to you....I feel your pain. ..

[shiftedsanity]

I guess I am confused. ..I read a post from someone on this thread talking about similar situation. ..now I dont see it?

[Deleted]

Wow.

[Mariposa(Heather)]

Hello All,
I have RBCBS of Oregon and just found out today that I was denied coverage for the DS. I completed my 6 month medically supervised weight loss program on July 1st.

Her is an excerpt from the email I recieved from Dr. Rabkins Financial Counselor today:

The good news is that your policy does cover bariatric surgery; the bad news is that your insurance considers the Duodenal Switch (DS) procedure to be “investigational” and therefore not covered. You can fight them, with our help, in hopes of getting them to cover the Duodenal Switch on an exception basis, if you’d like.

Do I need to make an appeal myself or just work with Dr. Rabkins office?

Thank you for any input.

[Deleted]

Did I read correctly that you said your HR department told you to lose weight or be fired? I would be documenting all of those conversations.

[shiftedsanity]

Yes they did

[shiftedsanity]

..I guess I have a second class disease...alcoholism treatment is a full
covered. ...obesity treatment is self pay WW.....lol

[Mariposa(Heather)]

Thank you Diana!

[shiftedsanity]

I had regence send the documents for WLS and i also got the Insurance book info today.

Regence policy

I.
Gastric bypass using a Roux-en-Y anastomosis with an alimentary limb of 150 cm or less, sleeve gastrectomy as a stand-alone procedure, or adjustable gastric banding, consisting of an adjustable external band placed around the stomach, may be considered medically necessary in the treatment of morbid obesity when all of the following criteria are met:
A.
At the start of the medically supervised, nonsurgical weight reduction program:
BMI greater than or equal to 40 kg/m2; or
BMI greater than or equal to 35 kg/m2 either with a diagnosis of type 2 diabetes mellitus or with at least two of the following comorbid conditions which have not responded to medical management and which are generally expected to improve as a result of obesity surgical treatment:
1)
Hypertension
2)
Dyslipidemia
3)
Coronary heart disease
4)
Sleep apnea
B.
Documentation of active participation for at least six months in a structured, medically supervised nonsurgical weight reduction program. A comprehensive commercial weight loss program is an acceptable program component, but it must be approved and monitored under the supervision of the healthcare practitioner providing medical oversight. Comprehensive weight loss programs generally address diet, exercise and behavior modification, e.g., Weight Watchers.
Documentation from the clinical medical records must indicate that the structured medical supervision meets all of the following criteria:
1.
Occur during at least 6 consecutive months within the 24 months prior to the request for surgery; and
2.
Include at least three visits for medical supervision, occurring at intervals of no longer than four months apart, e.g., at the start, middle and end of the 6-month weight loss program; and
3.
Be provided by an MD, DO, NP, PA or a registered dietitian under the supervision of an MD, DO, NP, or PA; and
4.
Include assessment and counseling concerning weight, diet, exercise, and behavior modification; and
C.
Evaluation by a licensed psychologist, psychiatrist, or LCSW documents the absence of significant psychopathology that can limit an individual's understanding of the procedure or ability to comply with medical/surgical recommendations (e.g., active substance abuse, eating disorders, schizophrenia, borderline personality disorder, uncontrolled depression); and
D.
Clinical documentation of willingness to comply with preoperative and postoperative
5 - SUR58
treatment plans; and
E.
Age greater than or equal to 18 years.
II.
Adjustable gastric banding, gastric bypass using a Roux-en-Y anastomosis, and sleeve gastrectomy are considered investigational for the treatment of any condition other than morbid obesity, including but not limited to gastroesophageal reflux disease.











III.
The following surgical procedures are considered investigational for the treatment of any condition, including but not limited to morbid obesity and gastroesophageal reflux disease:
A.
Mini-gastric bypass (gastric bypass using a Bilroth II type of anastomosis)
B.
Distal gastric bypass (long limb gastric bypass, i.e., >150 cm)
C.
Biliopancreatic bypass (i.e., the Scopinaro procedure)
D.
Biliopancreatic bypass with duodenal switch
E.
Two-stage bariatric surgery procedures (e.g., sleeve gastrectomy followed by gastric bypass, sleeve gastrectomy followed by biliopancreatic diversion)
IV.
The vertical banded gastroplasty is no longer a standard of care and is therefore considered not medically necessary.
V.
Reoperation
A.
Reoperation for the following documented significant complications of a bariatric procedure may be considered medically necessary:
1.
Band erosion or migration
2.
Leak
3.
Obstruction
4.
Staple-line failure
5.
Weight loss to 80% or less of ideal body weight
B.
Reoperation in the absence of the complications in V. A. above is considered not medically necessary, including but not limited to reoperation for the following indications:
1.
Early satiety
2.
Failure to lose weight
3.
Nausea
4.
Patient dissatisfaction
5.
Conversion of a prior procedure to a different procedure (e.g, laparoscopic adjustable banding to gastric bypass) 6 - SUR58
VI.
Endoscopic procedures:
A.
Endoscopic procedures as the primary bariatric procedure are considered investigational.
B.
Endoscopic procedures, except for balloon dilatation of anastomotic strictures, are considered investigational to treat complications of primary bariatric surgery, including but not limited to weight gain due to a large gastric stoma or large gastric pouch and dumping syndrome.
C.
Examples of endoscopic devices/procedures include but are not limited to:
1.
StomaphyX™ (EndoGastric Solutions, Inc)
2.
ROSE procedure (Restorative Obesity Surgery, Endoscopic ™)
3.
EndoCinch™ (Bard)
4.
EndoSurgical Operating System™ (EOS) (USGI Medical, Inc)
5.
Sclerotherapy of sto

[shiftedsanity]

the two pages used to outline reason for denial are page 14 and 19...this is theses WLS reasons ...found in the policy above

Investigative Treatment means the use of any treatment, procedure, facility, equipment, drug, device, or commodity, regardless of its Medical Necessity, deemed by Regence BSI to be either investigative, experimental, or in the early developmental stage of medical technology. The determination by Regence BSI will be based on objective data and information obtained by Regence BSI and reviewed, by competent medical personnel, according to the following criteria:
1)
The technology must have final approval from the appropriate government regulatory bodies.
2)
The scientific data and data obtained through actual medical experience regarding the technology must be sufficiently comprehensive to permit Regence BSI medical personnel to reach well-substantiated conclusions concerning the effect of the technology or health outcomes.
3)
The technology's overall beneficial effects on health outweigh the overall harmful effects on health.
4)
The technology must be as beneficial as any established alternative.
5)
When used under the usual conditions of medical practice, the technology should be reasonably expected to satisfy the criteria of sections (3) and (4).
The determination referred to herein will be within the exclusive discretion of Regence BSI and may or may not be in accord with some medical experts' opinions on the acceptance of the technology as established medical practice



26) Treatment for obesity or weight control, including surgery or other treatment (including any complications) for obesity including Morbid Obesity or weight control, even if the Beneficiary has other medical conditions related to or caused by obesity. This exclusion will not apply to a Bariatric Surgery covered according to Bariatric Surgery section.

[shiftedsanity]

It feels like I am swimming in shit (more like dog padling).
I am trying to understand all of this.
How can one BC/BS allows and another deny?
How can they demand pre-weight management, when it has been determined to have no outcome on the success of pateint?
Does the ASMBS not hold water with RBCBS of idaho?
How can RBCBS of Idaho give my surgeons Pateint coordinator information t hat was completely different than this on her initial call and set me up for so much time ,money, and heartache?

At one point in my life I thought most surgeons had a God complex.... now I know it is the insurance companies playing God

[shiftedsanity]

The company had me sign an agreement to those conditions. I was.advised to do so by my union to keep my job. I questioned the decision. Don't feel like I have much of a case now that I agreed to it. They can not supply the safety equipment required for a person of my size...ie ladders are not rated over 400 pounds. I dont wish to remain this size and I thought I would be less with the sleeve. The weight and metabolism are making loss a constant struggle. Now the mental pressures are also adding to the battle. I just want to have the tool to finish this and from what I have been advised and what I have read...the DS makes the best option. I just dont understand why HR is not supporting what they demanded I do.


get.a PCP ...get help...adhere to it.....and solve this
.
..I am starting to obsess over this....its effecting every aspect of my life....my wife has told me she doesnt know this me..

sad

[shiftedsanity]

I have the book as of 4 pm today....I will be getting all that info sorted out...thank you so much for helping me...
you truly ROCK...to be continued

[larra]

Shifted, no one here can help you more to sort out your convoluted insurance situation than Diana. I won't try to add to her excellent advice, because I can't. So I will simply say, whatever happens and whatever obstacles you encounter, don't give up! Somehow, even when this type of situation seems insurmountable, things do often come together.

I agree with you completely that DS is your best bet to get the most excess weight off possible and to keep it off permanently. You have your goal, it's a good goal, dont' allow anyone or anything to discourage you.

Larra

[shiftedsanity]

Diana and Larra ... thank you
I am strapped. My legal funds don’t exist. If I could afford a fight, I could afford a Surgeon. All I have done in the past years has been on my dime. I am out of dimes now. No disrespect.

I admire you and your dedication to helping all in need. Mistakes, I have made many. I have beaten myself up enough for all these mistakes/failed attempts at securing a healthy future. I just can’t focus on the path I traveled. I need to focus on the road ahead. If I lose sight of the goal of an insurance appeal, I will be mentally and physically destroyed. The work/weight issue has to take the back burner and the surgery approval the fore front. Trust me when I say, I have lost enough sleep over the way this went down.

As far as my insurance booklet goes
XXXXXXX XXXXXX Corporation has an administrative agreement with Regence BlueShield of Idaho (BSI). As our contract administrator, Regence BlueShield of Idaho provides identification cards, processes all claims, and makes benefit payments on our behalf. Because this Plan is self-funded through XXXXXXX XXXXXX Corporation, it is not insurance and does not participate in the Idaho Life and Health Insurance Guaranty Association Act. It is the goal of Regence BlueShield of Idaho to provide you with high quality, low cost health care while maintaining the highest level of service to you and your dependents.

Thanks again

[shiftedsanity]

I was not involved with Dr. Rankin..
that was another RBCBS of Oregon post added to this board.

I am a with Dr. M. Srikanth in Federal Way Washington. I was told by his staff, he had writen two appeal letters already and I would have to either self pay or fight forward from here. So when it gets to that point, I will review those prior letters and go from there.
I will also be talking to PCP as well....thanks

[shiftedsanity]

Tomorrow I start my 4 days off. I am going to try to get into see my mental health provider and my PCP. I am not sleeping much and hopefully I can get some answers or help dealing with this.

I am still in the wait stage on all my records and that isn't helping. I hate the idea that there is real help just beyond my grasp. I was also told by Regence they would contact me on Tuesday. I have never been good at waiting. So hopefully I will be able to say it was worth the wait.......but somehow I think its only the beginning of a long drawn out process that they have down to a science.

I must say reading how well people are doing is giving me hope I will win this life long battle. The inspiration helps in the down time. I can only hope I will be living the DS life sooner than later.

keeps the loonie bin at bay. Thanks all

[Leonie]

I can so identify with you. I reached a point where I knew I was slowly dying. I was desperate. In that place I started researching wls. Within the first weeks I discovered these folks and knew that the bypass was not an option. I sat in the surgeons office. He said he does the DS, but refused to tell me how many. All the people in the waiting room had rny.

There was no way we could even afford the higher insurance and excesses.

I knew absolutely no one who has had any surgery.

Then the miracle happened. Hubby got retrenched and immediately offered a new job. I grabbed the money and ran to a very special offer. I got my DS, my health and my life. It was tough on hubby. He was going through retrenchment, and all I was thinking about was surgery, travel, and recovery. He took a serious knock but we are surviving, I am thriving.

You can do this.

[shiftedsanity]

Thank you lulu......great job btw....been amazed at how well people are doing. ...also I read the math. ...makes me scratch my head. ..."calories in" never seemed to work for me. ...at my weight I think I read I ld need over 4k to maintain my weight...very fuzzy math.....but I see on the DS it is a "new math" I will learn and you DSers have proof it works..
Way to go all you posties...hat's off to you

[shiftedsanity]

Saw the head healer yesterday. I have never enjoyed "anti-drugs". But I am going to give em a try and see it I.can.get some relief.

Been on the phone half the day. Time divided between air conditioning being out and appeals process paper collecting. So not a great day off. Spent quality time with my insurance help specialist (bless her heart) and she was more than helpful getting my information faxed to my PCP. I also have been calling all my providers for letters supporting the need for surgery. I keep hearing that one line in a Greatful Dead song...
"What a long strange trip it's been".....I guess I have to "keep on truckin"...

I was told my next step of review is outside of Regence....that springs hope...crossing my fingers.... .dotting my Ize...check check and recheck....
then see what my big brain friend's (that know how this game is played,)think and advise....you know who you are...and I hope the liberty of the friends" reference is not off putting or reachy

[napolilu]

Sorry I am not sure how to post but please read:
Hello,

I need some advice please:
My insurance is kaiser, I quality for weight loss surgery since my BMI is 46. I asked the surgeon at kaiser to be referred out of kaiser for the DS - since they do not perform the DS-
Kaiser replied that since my BMI is below 50 they do not refer outside for the DS.
I filed a grievance form for my case to be reviewed and want a statement from me. I am not sure what I should say... Can someone help please?
Also, they want my statement by the 15th of July.

[shiftedsanity]

The "Wonder Women" to the rescue.... Amazing place here with amazing people.... again "hats off' to all the gaurdian angels assisting the pre-ops...If even one person gets through to the other side of surgery, its a blessing

[shiftedsanity]

Lol...that picture brought back some bonus memories. ...great super hero outfit...

Why be Diana Prince when you could be a Diana King?..

Does your "lasso of truth" help fight the evil insurance villians....when all else fails toss the tiara....
I don't have your email to send that draft...or I am lost at finding it....says hidden.....and was only curious if I was on the right track before I post it for the boards. I have a small mountain of support docs I am adding to my appeals folder as well. I was worried about being too winded in my intro....thinking I want to try to hit them in steps....anyway will send word doc when I get your email.....also any other info if needed....then when its closer to correct I will post to help others wanting an example.

question....do you two "time share" the super hero's outfit?....and how do you know where to refuel on the invisible plane....you go girlz