Thought I would bring my situation regarding my struggles with BC/BS over denying my having back Surgery. My Surgeon had filed a Level 2 Provider appeal back around June 10th after they upheld their denial of the first Peer to Peer appeal. On July 10th they again upheld their denial, waiting the full allowable 30 days to answer. I had been on the phone with them at least twice a week during that time and was told up until the 19th that no decision was made. I scheduled this procedure May 30th in order for my wife to be off from work with the Bristol School System. They have effectively made this plan useless, and really ruined much of our Summer as far as making any plans or taking any trips. The crux of the matter is they have taken a examination by a Physician's Assistant in which he noted I had no pain, spasms and walked with a normal gait without assistance, all of which is pure nonsense to the point of ludicrousness, and used it as their reason over the comments of a Neurosurgeon. Those on here that have seen me, hat, Jay, IP, KPT, Macon, NYY, and others that memory fails, know just how ridiculous this statement is. This PA was fired from the practice because of this type of thing according to the lady I have been working with. Anyway I have decided the most effective way to end this bull shit is to go down to their office in Chattanooga and demand they examine me, and then tell me I do not need this surgery. I now have the name of the person who is in charge of the appeal committee, and will be sending her a letter telling her a day and time I expect to meet with her. When I arrive if she refuses to meet I intend to picket them until she does. Should this happen, if any of you in the Chattanooga area could give your moral support it would be helpful. I intend to stay however long it takes. Hopefully some local media will get involved.
The only way to get these bs denials over turned in my experience is to do exactly what you are doing. Hound them. The truth is on your side. They just make it so hard that nine of out ten people quit. Good luck!!
Might have a shred of credibility if there had ever been any situation ever where a PA would overrule a specialist. Good luck, RB.
Fight. And keep fighting. If you get tired let us help fight for you... I know where Chattanooga is on the map and can be there in 3 hours. And will be there.
I'm literally trying to fathom how you can even begin to say a PA's word trumps a specialist, especially a neurosurgeon. I can't do it.
To date, I've not had any issues with them (knocks on wood), even a couple of times I fully expected I would.
You have whatever support I can give you, rb. Refuse to take no for an answer as I know you will. This bullshit of an insurance company employed "doctor" that has never examined a patient overruling the patient's physicians who have not only examined their patients multiple times but also have great expertise in their field MUST end. I don't see the chickenshits seeing you. They wouldn't even let me talk to one on the phone, but give 'em hell! Just a bit of advice, make sure you go ahead & file the 3rd appeal that is with an independent agency. Take the time to make this final appeal as detailed as possible. Include photos, videos & as many medical journal publications as possible along with any of your doctors notes and letters. This external appeal is guaranteed in your contract. It is often necessary to exhaust all appeals before any further measures, read legal measures, can be pursued. I beat these bastards in my final appeal. Maybe it will work for you too. If not, you've exhausted the grievance process within your contract (funny how they only hammer that contract bullshit when it benefits them). Once you've done that, you can proceed to seek relief from the courts. Don't mention lawsuit to them unless you've exhausted all other means. But if they continue to deny, sue their asses off & go for more than just the surgery cost. Money is all they understand. Best of luck! Keep us informed. You have my number if you need anything at all.
I cannot get my head around this either. Insanity. I got angry just reading what you've been through, RB. Whatever support I can provide is yours.
