HELP PLEASE --- BCBS keeps saying NO :(
By skuhns on 16 Oct 2012
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.