Denied by Blue Shield of CA as "Not Medically Necessary"

[MPL 9]

After trying to accumulate all of the information and jump through all of the hoops since JANUARY, I learned today that Blue Shield of California denied my sleeve surgery as "not medically necessary." I have so many comorbidities that I have to ask, "what the [blank] does it take?" I have severe sleep apnea, fibromyalgia, lymphedema/cellulitis, depression, neuropathy, knee and foot pain, a BMI of 45, and I am post-stroke. I am dependent on a cane or walker.

I was originally told (at my surgeon's office; they now say they didn't, but I took notes and so did the friend I brought with me) that although BSCA usually requires 6 months (or 2x 3 months) of a doctor-supervised diet program they would probably either waive that requirement because of my other health problems or accept my my history of weight loss efforts which nearly met the requirement. Now I am told the requirement is 6 continuous months within 18 months, no waivers. Had I known this in JANUARY, I could have completed another go-around by now. Of course, I couldn't afford to do that then and can't now-- and my insurance doesn't cover the cost of a medically-supervised diet!

I have done the psych eval and cardiologist appointment, which that office assured me would be covered by insurance since it was a requirement of the surgeon. Who knows what will happen with THAT. Fortunately, I was able to cancel the nuclear stress test. The cardiologist's nurse said she had never heard of someone being denied after the surgeon's referral to the cardiologist. (It would not surprise me if the surgeon's office just sent me to get a cardiologist's clearance so I'd feel like something was happening; the office has misplaced my paperwork, claimed they didn't get other paperwork from several other doctors, and generally been very lackadaisical about the whole thing. It's clear they'd rather deal with patients with "easier" insurance.

I am so frustrated and feel so defeated. I am usually a fighter, but I am so tired.I have absolutely no resiliency. My world just gets smaller and smaller as I am able to do less and less. I do an arthritis swim class 4 to 6 times a week but I am wiped out for the rest of the day. I NEED to get back to work. I am "only" 59 and not ready to be elderly yet! (My 84 yo parents and I compare symptoms...)

How does a person fight "not medically necessary?" If you are too sick they won't do the surgery!

Would it help to involve an attorney? Does anyone know an attorney specializing in denial of medical treatment?

Any suggestions of how to move this forward would be very much appreciated.

[peteyrulz 82]

I'm sorry that they're putting you thru this. With a BMI of 45 + the co-morbidities I am very surprised you were not approved. I strongly recommend you appeal thru your surgeon if possible; they can do a peer-to-peer meeting where your physician can work with insurance drs. There are obesity advocacy attorneys who can help as well, Lindstrom is popular here. wlsappeals. com. ( Not affiliated)

Good luck & HTH.

[sunnkistme 76]

It sounds like they may have just given you "not medically necessary" instead of didn't jump through the right 6 month hoop!

Your can appeal or go through the 6 months and try again. Somewhere on here someone said BC/BS was no longer demanding the six months. I thought it was too good to be true.

[kd5wzr 108]

Ask Blue Shield to provide you with their policy for bariatric surgery and review it carefully. For example, Anthem BCBS posts theirs here. If they've denied you for reasons not explicitly stated in their policy as reasons they can deny service, you should immediately appeal. If they still deny you after appeal based on reasons not stated in their policy, you should consider hiring an attorney or going to the local media. It's not okay for a company to make a policy and then refuse to follow it when they just don't feel like it.

[JenSul 21]

Wow! I'm so sorry! That doesn't even make sense! Not medically necessary? Did they not even look at your file before they denied it? I can see why you are tired and have had enought. I really hope you can find it in yourself to continue. Best wishes from MA.

[BeagleLover 1,020]

PLEASE don't give up! That's what they are hoping for!

[momohime 121]

Perhaps surgery is "not medically necessary" because you don't have a PCP of some sort to recommend surgery/validate your surgeon's recommendation. Or maybe you do, but their records aren't up to insurance standards. Insurance companies are generally not on your side and are sticklers for their requirements. My surgeon's office was very specific when they told me about doing my 6 months, down to even telling me how my GP was supposed to code my visits. Since you didn't meet the 6 month diet requirement, insurance could say no because.. well, they just can. I don't say this to bum you out or anything.. Honestly, I don't think it makes much sense either. I could totally be wrong, but don't lose hope yet! If that is the case, it may be possible for you to still do your 6 continuous months and still be approved for surgery. If your insurance won't cover your visits, you can usually talk with your PCP's office and arrange a self-pay option.

Either way, it sounds kinda like your surgeon's office dropped the ball a little bit by not clarifying anything with you. It also sounds like they were pretty certain you would be approved, otherwise why send you to the cardiologist.. I'm actually a little surprised they aren't working harder on getting your insurance to move forward. I was denied initially because I submitted pictures instead of 2 years worth of height/weight records. Once my claim went to an actual agent and not just through their automated system, I was approved.. so there's another possibility as well.

I think you might receive a denial letter from your insurance that might explain things better, but I would still call your surgeon's office to see if they can explain exactly why you were denied. You could also call your insurance company directly and ask them. I can't offer any advice other than that because that's as far as my experience goes, but I really hope you get everything worked out one way or another!

[MPL 9]

Peteyrulz, I took your advice and contacted Lindstrom. Kelley was so helpful had great information that made me feel a little less powerless and a little more hopeful.. I will be trying this after I clarify with my dr.'s office that they aren't doing anything further. Thanks for the reference!

All of my doctors-- including a very supportive PCP-- are shocked at the denial, but every one of them had a story to tell about recent problems with Blue Shield of CA. It's a shame that when I finally need to use it for something substantial, they aren't there, but that's the go-away game they are playing, I guess.

Thank you all who responded-- I appreciate the advice, stories and support!

[Jersrose43 837]

Peteyrulz, I took your advice and contacted Lindstrom. Kelley was so helpful had great information that made me feel a little less powerless and a little more hopeful.. I will be trying this after I clarify with my dr.'s office that they aren't doing anything further. Thanks for the reference! All of my doctors-- including a very supportive PCP-- are shocked at the denial, but every one of them had a story to tell about recent problems with Blue Shield of CA. It's a shame that when I finally need to use it for something substantial, they aren't there, but that's the go-away game they are playing, I guess. Thank you all who responded-- I appreciate the advice, stories and support!

Have you called blue and ask them why they denied it? Speak to them and save your money

Sometimes I find that if you just talk to the rep they can tell you bullet point by bullet point what was missed in the submission

Since you stated your surgeons team is acting lackadaisical it's possible (very possible) that they missed something In the filing.

That happens more often than you think.