HELP PLEASE --- BCBS keeps saying NO :(

  • skuhns
  • 2 years ago

Hi all.  I've been "fighting" with and "jumping through" BCBS's hoops since March and I don't know where else to turn.  I am a 37 year old first grade teacher.  I am a full 38DDD.  I am 5'10' tall and weigh 202 lbs.  My legs and arms are very muscular from sports when I was younger.  I know that muscle weighs more than fat.  I am not flabby or fat, but BCBS says I need to lose weight.  I don't qualify for surgery based on the Shruner Scale.  My PS has requested 550-600 grams to be removed from each breast.  BCBS says that because of this scale, I need 819 grams removed per side.  I meet every other criteria other than this scale.   In order to qualify for what the PS suggests, I would need to weigh about 140.  My PCP, my Chiro, and my Ortho. all say that this is an unrealistic weight for me, but BCBS will not budge.   I have been denied.  The PS did a Peer to Peer and was denied.  I sent in my level 1 appeal and received notification yesterday that I have been denied again!  I am not working on tweaking the initial appeal to resubmit to the Level 2 appeal board.  After the Peer to Peer denial, the PS said there was nothing more he could do for me and that he was sorry - so I am now working with a new PS who is submitting his initial request for coverage tomorrow.   Does anyone have ANY suggestions to help me?   I am so frustrated!  I offered to meet with whomever so they could see me as a person, not a number on a scale, but no one will do that.     I am really coming down to the wire here.  We need to get approval before the end of the year because we have worked so hard to meet our deductibles and are less that 10.00 away from full coverage.  We pay so much into the system for all the appointments, pain meds, muscle relaxers, therapy, etc.  Don't they realize that will all go away if they would just approve the surgery?!        Super Sad in NC.  

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Sorry I haven't updated...well...here goes. My surgery was Dec. 7, 2012. When I went in for my pre-op markings that morning, my PS looked at me and laughed! He said in his 30 years of practive, he has NEVER seen anyone beat BCBS!!! I told him BCBS had never met the persistency of ME before! So, we moved on to the markings. We talked about what I thought I 'needed to be'. I told him I know I can't go small because I'm not a small person...I'd be happy with a C or even a small D. He seemed thrilled - he said he was worried that I'd want to be a small B or something and he was afraid we were going to "go rounds"! No, I'm realistic - I told him. I'd LOVE to 'chop em off and go home' but that's not realistic. He met me across the street at the hospital 2 hours later and they wheeled me in. That's all I remember. When I woke up, I was in recovery. My husband had left during the surgery to get my children from school and bring them to the hospital...I thought I'd be fine since I was going home afterwards. ***BIG MISTAKE*** Make sure you have childcare the day of surgery and overnight...my kids had to sit in recovery (thank God for iPhones and iPods) until I came out of anesthesia...then they had to see me go home still WAY groggy. Again - find someone the keep the kids!!! General Anesthesia makes you totally loopy and it wasn't a good sight for the kids (they are 8 and 13 so they thought it was pretty funny). I came home and went straight to bed. Thankful my husband volunteered to sleep on the couch - I took up the entire king sized bed with pillows under each arm make sure I didn't roll over and to support the drains. The drains...I do NOT have a weak stomach, but for some reason, the drains grossed me out! Todd emptied them twice a day and he was fine with it, but ewww...I went back to the dr. on Monday (my surgery was Friday) and the nurse took the drains out. I then had to go back on Friday for my 1 week post op. At the 1 week appointment, she snipped my stitches and gave me the best instructions: Slather Palmers Cocoa Butter on the incision sites, then cover the cocoa butter with 3M white tape (found in with the band-aids) and the steri-strip gluey stuff would come right off. It worked great! She said to use the cocoa butter instead of the Mederma for the scars as well. Cocoa butter is WAY better. She was right! I went back today for my 6 week post op. The doctor came in and was amazed! He said he has never seen anyone heal so quickly; must be his 'fantastic work'. I totally agree! I have very minimal scars left (they are noticable, but not red or raised at all! The only part that is still red and raised is where the drains were; on the sides where the side bra seams sit. He said they will continue to improve if I continue with the cocoa butter. Dr. said I was doing so well, I don't have to return for my 3 or 6 month check up! I guess my journey is done! Good luck to anyone going through this. My main advice when it comes to insurance --- be the squeaky wheel. Appeal, appeal, appeal. they will get sick of you and they will listen after a while! Super Happy in NC!
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I got the call at 12:30 today...I WAS APPROVED!!! Once they fax the authorization number, i can get scheduled for either Dec 4 or 5!!! I am so excited!
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Hooray! I am so happy for you.
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Thank you! I am so excited! Dr says Dec 4 or 5!!!
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Awesome!! I'm still waiting to hear. It will be almost a month since the letter was sent.
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Lucy - have you heard anything yet? I'm praying for you.
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I have had daily headaches for over a year. Seen every doc from ENTs to neurologist, to eye doc, to allergist and more. Had MRI and CAT scans and heart tests. But my regular doc told me that I still had to do physical therapy for 6 wks (2 x wk) before I'd qualify. I did it and got approved the first go round. You didn't mention if you had any physical problems from your breasts.
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I did have the headaches, backaches, etc. My chiropractor conferenced in on my final appeal and he was awesome --- he used all the medical (mumbo-jumbo to me) and explained exactly which L4, L5,C2 etc. that is deteriorating, that the artheritis is expanding, and that there is no other option for me than to have the surgery. I made him a Steeler wreath as a thank you for everything he did to help out!
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Before I even had my consult, I looked up the criteria for my insurance company. They had a number system, and if you scored at least 5 then you would qualify. I have documented back and neck pain for years, I have numbness and tingling in both arms - those criteria ALONE qualified me. Good luck!
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My best advice to you is to get your doctor very familiar and make sure he is fighting for you! Please dont get discouraged if they deny again. If they deny your appeal you may have to find a different plastic surgeon and try again. Sometime the insurance companies will deny your claim because the doctors fees do not fall under the allowed amounts. Keep your head up and keep trying, it will be worth it in the end. They make the process so difficult so it will detour those who are only in it for cosmetic reasons. Just dont give up!
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Any word yet on your newest appeal? I also have coverage through BCBS and dread the results.
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@ soilschick - I was approved when I went back to the PS with the letters, x-rays, chiropractor recomendation and physical assessments from my PCP. My insurance paid 100%. Remember to keep appealing. Call BCBS and find out exactly what their requirements are to qualfy for a breast reduction. Most insurance plans will require a certain number on grams removed, prior treatment from a chiropractor to help with symptoms, a physical assessment from your doctor, x-rays, statement from your doctor with muscle relaxers/pain prescriptions that you have tried already, and pictures. If you re-submit with all of this info and you meet the gram removal requirement I dont see how you can be denied. My insurance plan didnt require a certain amount to be removed but most plans do. Get familiar with BCBS requirements and try again. Dont give up, thats what they want you to do!
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My appeal hearing - via telephone - is November 20th at 12:00 noon. They said i can have anyone phoned in that i want, but it will only be one person on the other line. Hoping my doctors and i will be able to convince this person!!!
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How did your appeal go skuhns? I am happy to say that BCBS approved my surgery today.
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I was denied at first. I appealed, won, and didnt pay 1 single cent for my reduction from United HealthCare. I dont know what worked for everyone else but i can tell you what worked for me. I went to my primary care doctor, told him what i wanted. He agreeded and wrote me a recommendation letter. He performed an exam and x-rays and gave me the assessment, x-rays, and letter to take to my plastic surgeon. I also went to my chiropractor. He wrote me a letter of reccomendation and also gave me an assesment to give to my plastic surgeon. I foound an in-network PS and he performed and assessment, submitted all of my letters, exams, x-rays and pictures to united healthcare and then they approved. Hope this helps.
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That was my case as well and why it took me 7 years to get the BR done. I ended up doing self-pay and saved each year just for that. Totally unfair and I wish I could give you words of wisdom but I don't have any. The Insurance groups seem to have it out for this type of procedure when its truly a medical necessity.
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Okay, so after reading the above - I noticed a big mistake where it said I wan NOT doing any more appeals. I most certainly AM! I faxed my Level 2 Appeal as well as my request for an External Review Hearning out yesterday afternoon. The appeals consisted my me pleading my case once more as well as letters of rec. submitted through my PCP, my Chiro, and my PS. If anyone has any other suggestions, I'm more than willing to try ANYTHING at this point! I'm a first grade teacher and the pain of working in itself is hard, let alone everything else that a mom of 2 has to deal with on a daily basis. Thanks again for any suggestions.
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