My VSG approval Process Anthem Blue Cross Medi-Cal

[shawnee1973 26]

I decided to write this timeline because I feel that it is important for other people to understand this process and what to expect. In May, 2014, after careful research, I decided that I wanted to have gastric sleeve surgery. I have struggled with weight my entire life. Although I have never had any major health issues or what most insurance companies consider co-morbidities, at the age of 40, my weight was starting to affect me.

I began my research with Anthem Blue Cross, making sure the procedure was covered and to understand their specific criteria. I knew ahead of time what labs and x-rays I needed. My first trip to my PCP was early June. I knew that at a weight of 225 and height of 5’4, my BMI was between 39 and 40 so I put on an extra 10 pounds so that I knew I would be covered. She ordered all my tests. I found a hospital (Bakersfield Memorial) and surgeon (Dr. Snyder) that I liked and scheduled a seminar. When I spoke to the nurse who schedules everything for the surgeon, she informed me that how fast this process takes will be up to me. This is why I had all of my tests done prior to my seminar in July. I was ahead of the game believing that a six month wait time was not going to apply to me.

Labs, xrays, ekg, abdominal ultrasound all looked great so now it was time to get my surgery consult. Of course this requires an authorization from my insurance. It was at that time that PCP staff advised me that they were way understaffed and authorizations can take up to two months. This was ridiculous in my opinion so I became a major pain in their ass. After about a month, I was informed that my authorization was denied by my insurance because it was not a covered service. I called Blue Cross who informed me that they have nothing to do with authorizations. My medical Group (Independence) must have denied it but I could not contact them directly. Blue Cross attempted to contact them for me but had to leave a message. I finally returned to my Drs office only to be told that my paperwork was misplaced so she could not give me a reason for my denial. After much persuasion, she gave me the number to my medical group. I spoke with the assistant director of Utilization Management who then informed me that my Drs office put the authorization in as a behavioral health consult rather than a surgical consult. She corrected it right away and gave me an authorization number.

I called my surgeons office and scheduled my consult for September 10^th. The nurse informed me that I should wait until after the consult to schedule my psych eval and nutrition consult. I decided to get the nutrition consult done prior to the surgery consult because it was covered by my insurance. The consult went great and I was told as soon as they received the psych and nutritional paperwork, they would submit it for approval. Once approved, they could get me in right away for the surgery.

I decided to pay extra for my psych eval because he works directly with this surgeon and guaranteed he would send the report the next day. 4 days after my consult, I was done with everything. A week went by, I heard nothing. I called the nurse who informed me she had received the nutritional report but it was cut off in the fax. And she had never received the psych report. I called the psych office who faxed that paperwork right away but still could not get that nutrition report to fax correctly. I decided to make the 40 minute drive to pick up the report myself. After all, the nutrionist assistant was on vacation and she didn’t know how to fax. How do you have a college degree and not know how to fax? So finally, all paperwork was in and the nurse sent it off for approval. Actually, she submitted it to the hospital staff who took another two weeks to send it for approval. Another week went by only to learn from Independence Medical Group that my insurance company denied me because I did not meet the criteria. We wouldn’t know what that meant until I received the denial letter and then I could appeal. I was so angry. I knew that I met the criteria, which was a BMI over 40.

Another week went by and the surgeons nurse called me to say that I needed two co-morbidities. I explained that it was incorrect and I had already contacted Blue Shield to make sure that I had it correct. So instead of making phone calls to get this straightened out, she told me the surgeon was going to order more tests to try to find something wrong with me and we could re-submit everything and try again. This blew my mind. Instead of getting to the root of the problem, let’s spend more money. So, I contacted Independence medical group who stated they denied it based on Blue Cross criteria and if their criteria was incorrect, Blue Cross would have to notify them. I contacted Blue Cross who then contacted Independence Medical Group to get it all straightened out. So now it was back under review until they received the correct guidelines. Two more weeks went by, no change, no denial letter, no review, no nothing.

Needless to say, my level of frustration was very high. I decided to call Independence Medical Group and by some great fortune the assistant director who helped me before answered. I explained the entire situation to her and she approved it again over the phone and educated her staff. A second approval was required through Blue Cross which took a couple more days. But as of Friday, November 14, I am officially approved. The Surgeons nurse called me to congratulate me and inform me that they probably couldn’t get me in till after the holidays but she will call this week to let me know for sure.

The entire process when all is said and done will probably be 7 to 8 months but I did not give up. I will have this surgery. I just want anyone struggling with the approval to understand that not too many people are going to go out of their way to help you. It is up to you to make the calls and bug bug bug. Turns out the assistant director has WLS herself so she was a big advocate. If it had not been for her, I may still be fighting this.

[mz.newlife54 103]

Congratulations and good luck with your surgery. Nice to be determined. Proves how much you want this.

[just4myra 18]

Persistence definitely is a must in this process. I'm awaiting insurance approval myself. I pray it all goes well. Good luck to you and Congrats!

[shawnee1973 26]

Thanks ladies and good luck to you both!

[bamagirl 31]

That is awesome to hear! I am on round two of insurance approval after being denied 2 years ago. Best of luck with your surgery and wishing you a speedy recovery!