Pound4Pound
Can you belive it? WTF?
Jul 27, 2009
I would like to start this out with “You are not going to believe this”, but I already know that most of you will. I can say honestly that I do believe they said it, but it still amazes me how asinine “The Evil Empire” (a.k.a. BlueCross BlueShield) can be. To bring you up to speed on things: Back in May of 2009, Dr. Smith’s office submitted paperwork to BC/BS for pre-approval. A month rocks by and they deny me by saying what they always say. “The BPD/DS is considered “investigational” and therefore is a non-covered procedure”. I then hired an appeal specialist to appeal my case to my company’s human resources department. I work for a self-funded company that has a history of supporting the duodenal switch. My HR department took their sweet time, but came back with a decision in my favor. They instructed BC/BS to cover the duodenal switch if in fact I meet BC/BS’s criteria for bariatric surgery. All seems well…….. Two weeks later Dr. Smith’s office gets a letter stating I must prove to them that I’ve been MO for at least three years. This is BC/BS’s official policy regarding the 3 year matter; The condition of morbid obesity (BMI ≥ 40 or BMI ≥ 35 with presence of comorbid conditions) must be of at least 3 years duration. There must be documentation in medical records by a primary care or attending physician of patient height and weight for the past 3 years. A letter from the primary care physician and dated photographs will be considered in lieu of recorded heights and weights. Random reviews of these patients’ charts for accuracy of stated information will be conducted. Notice the italics part above? Well that is the route I went, because frankly I’m not a run to the doctor kind of person. I don’t really have consistent medical records due to the fact I never go to the doctor. Anyway I submitted several photos that were not actually dated, but they were of me with my kids as they were growing up. I went back as for as 2004 when my son was born and my daughter was 5. They are now 5 and 10 years old. I mean it is an obvious transformation. That just seems to me to be better than dating. You can fake a dated photo a lot easier than you can fake a 2 month old baby turning into a 5 year old kid. Geez! Now I will move on to the letter from my PCP. I will put it out here word for word with the exception of omitting my last name. Please read it along with BC/BS’s response to it, and tell me you find any sanity within it. Here it goes: Ref: William XXXXXX DOB: 05/XX/XXXX To Whom It May Concern: Please be advised that I have been taking care of William XXXXXX for a number of years, and he has had morbid obesity as his diagnosis. Looking back at his record, he has had morbid obesity for his entire adult life. Nine years ago his weight was measured at 311 pounds, and it’s been between 311 to 350 ever since. I have numerous records in the chart of his weight being 311 to his current weight of approximately 350. This is not a new development. As stated, he has been overweight his entire adult life, and I believe it is now time to have surgical intervention for morbid obesity. Sincerely, Charles XXXXXXXX, MD Does that not clearly state that I've been a minimum of 311 pounds for the last 9 years?From BC/BS in response to above: Dennis C. Smith Jr., MD Patient: William XXXXXX Dear Dr. Smith, We are contacting you regarding the proposed treatment for your patient. Our medical staff is unable to make a predetermination for the proposed treatment at this time. In order to make a determination, our medical staff need medical records documenting the patient’s weight in 2006 and 2007. If the medical records are not available, out medical staff will need original dated photographs for 2006 and 2007. Please submit the requested information along with a copy of this letter to the following address: BC/BS of Alabama
When I called BC/BS to ask the WTF their deal was they actually told me that I must provide records from 2006 to 2007. I said my PCP's letter clearly states the I've been at least 311 pounds between the years of 2000 to 2009. She said that is what is says, but they need documentation for 2006 to 2007. I asked if she realized that 2006 and 2007 fall into the date range of 2000 to 2009 that my doctor testified to in his letter. This went round and round and round like a dog chasing his tail. I ended up just hanging up in her face before I started letting the "stupid muthafuckas" start flying outta my mouth. How do you deal with such idiocy?
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About Me
Prattville, AL
Location
26.2
BMI
Surgery
11/06/2009
Surgery Date
Oct 14, 2008
Member Since
