MERCYCARE - DENIED NEED HELP

[lawchica 1]

I have Arizona MercyCare (Mercy Care) AHCCCS Medicaid insurance. I have had Pseudotumor Cerebri (PTC) for three and a half years and I finally decided to look into weight loss surgery about 3 years after I was initially told to do it by my neurosurgeon to help the PTC. I started my 6 month physician monitored weight loss in March 2014. My weight fluctuated due to steroids and medications I was on for the PTC. Overall I lost 21 lbs, but one month I was up a few lbs. Because of that month, my surgeon's office said that was why I was denied the surgery. However, after speaking with the insurance appeals guy, he sent me what was sent to my surgeon's office:

"Failed physician-supervised exercise and nutrition program (with regular visits every 2-4 weeks). These must be documented in your doctor's progress notes. Exercise and nutrition programs must be for a cumulative total of 6 months or longer in duration. Details of low calorie diet and physical activity with accompany change in weight need to be documented in the medical record at each visit. Records must document compliance with the program and you must not gain weight during the program. The submitted notes do not show these"

So there are several reasons that I did not get approved. It looks like the surgeon's office needed to put more effort into their notes from my visits. Has anyone had to deal with this? It also looks like they are saying that I did not go every 2-4 weeks. I think the surgeon's office schedule my visits for the same date each month, which could be more than 4 weeks apart. (Usually there is a few more days from Nov. 1 to Dec 1 than 4 weeks). So what do I do? I've appealed and I am awaiting my appeal. My surgeons office has been horrible from the start. I had to start keeping documentation and now have the hospital's patient care person come with me to all meetings with the surgeon's office because of the lies and things that did not get done to begin with. They say they have changed a lot about the way they do their business after I made a complaint to the hospital and they lodged an official investigation. However, I still feel like this is going nowhere and I'm not sure what to do. I am in constant pain. I lost my job due to the PTC and haven't been able to hold a job since -- PTC requires a lot of sick days and doctor visits so it is hard to keep up with that and a job.

Does anyone have an appeal letter they would be willing to share with me? I am willing to share the letter I wrote as well if someone needs it. I don't know if it will work for an appeal though since I have not heard back regarding mine.

[MrsMike1 34]

Oh my! I am so sorry this happened to you. I don't have an appeal letter or anything but I wish you nothing but success in getting this resolved.

[BLERDgirl 6,417]

1. I don't think they are saying you failed to keep the appts. The wording they choose is off but I think what they are saying is you failed physician-supervised exercise and nutrition program that has regular visits every 2-4 weeks. The reason they put the 2-4 weeks bit in parenthesis is because they are explaining what type of doctor supervised program it is.

2. If you are unable to work because of you illness, have you applied for SSDI? If not, you should.

3. Since the requirement is that you must not gain weight and you did. Your PC should have documented why despite your best efforts you did gain weight. Namely that you tried but the meds caused you to gain. So it seems the key item missing is that there was no justification for your weights gains noted.

4. You can go forward with the appeal, but unless you think your PC will add those justifications in there and advocate for you, it might be worth your while find a new PC. Unfortunately you may need to start this process all over again under the new PC unless you can document how you are in constant pain awaiting this surgery. Even then they may want proof that the surgery will solve the problem.

[MrsB2007 90]

Any update on this??? I have this insurance and was wondering something similiar about weight gain due to medication.. My dr noted it, but still a concern of mine.

[becweaves 67]

I have Arizona MercyCare (Mercy Care) AHCCCS Medicaid insurance. I have had Pseudotumor Cerebri (PTC) for three and a half years and I finally decided to look into weight loss surgery about 3 years after I was initially told to do it by my neurosurgeon to help the PTC. I started my 6 month physician monitored weight loss in March 2014. My weight fluctuated due to steroids and medications I was on for the PTC. Overall I lost 21 lbs, but one month I was up a few lbs. Because of that month, my surgeon's office said that was why I was denied the surgery. However, after speaking with the insurance appeals guy, he sent me what was sent to my surgeon's office:

"Failed physician-supervised exercise and nutrition program (with regular visits every 2-4 weeks). These must be documented in your doctor's progress notes. Exercise and nutrition programs must be for a cumulative total of 6 months or longer in duration. Details of low calorie diet and physical activity with accompany change in weight need to be documented in the medical record at each visit. Records must document compliance with the program and you must not gain weight during the program. The submitted notes do not show these"

So there are several reasons that I did not get approved. It looks like the surgeon's office needed to put more effort into their notes from my visits. Has anyone had to deal with this? It also looks like they are saying that I did not go every 2-4 weeks. I think the surgeon's office schedule my visits for the same date each month, which could be more than 4 weeks apart. (Usually there is a few more days from Nov. 1 to Dec 1 than 4 weeks). So what do I do? I've appealed and I am awaiting my appeal. My surgeons office has been horrible from the start. I had to start keeping documentation and now have the hospital's patient care person come with me to all meetings with the surgeon's office because of the lies and things that did not get done to begin with. They say they have changed a lot about the way they do their business after I made a complaint to the hospital and they lodged an official investigation. However, I still feel like this is going nowhere and I'm not sure what to do. I am in constant pain. I lost my job due to the PTC and haven't been able to hold a job since -- PTC requires a lot of sick days and doctor visits so it is hard to keep up with that and a job.

Does anyone have an appeal letter they would be willing to share with me? I am willing to share the letter I wrote as well if someone needs it. I don't know if it will work for an appeal though since I have not heard back regarding mine.

Send me your email address and I'll send you a copy of my appeal letter