I am so upset, I can hardly speak. I began seeing Dr Daryl Stewart in January, 2012 to get the ball rolling on my coversion of VSG to DS. He filed a Pre-Determination with my BCBA Federal Plan in Feb, 2012.
They denied it for "member does not meet the criteria". I called them and was told because my VSG was not 2 years ago, I would have to wait,
So I completed all the requirements with Dr. Stewart, and he re-filed my Pre-Determination onf June 14, 2012. (My 2-year date for the VSG is June 21, 2010). BCBS again denied it. I called them, and they explained that....1) the denial in Feb was actually because "I did not comply with the nutritional and exercise program after my VSG."
WHAT? First I had heard of this, and the denial letter did not state this.
The customer service rep went on to say that this 2nd Pre-Decision denial was for the same reasons, and...."I am only allowed to submit a Pre-Decision two times. After that, I can not submit again."
WHAT? So, I said "So, I can never, ever have this procedure under BCBS. EVER, because BCBS did not tell me or my doctor the real reason for the denial back in Feb, so that we could debate that reason for the decision (I did indeed comply with the nutritional program after the VSG).
I ams tuck in BCBS hell. They cannot simply say that my doctor can only submit something for consideration on two occasions and then I am out of luck.
I'm calling Dr. Stewart's office on Monday to see if they can intervene...maybe he can talk to the Pre-Decisional doctor, one-on-one...
Anyone else had this situation?
I suppose I can self-pay, but I really don't have $20,000, and it's the principle of the matter.
Any advice? Thanks everyone