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Florida Bluedenied authorizations submitted by surgeon

1
D Nov 30, 2017 Review updated:

Thanks to florida blue, I have been discharged from my surgeon's office, because their two requests for surgery have been denied and they can't keep fighting. The surgeon's office said "florida blue continues to deny everyone with the same insurance". Florida blue better pray to god that something does not happen to a patient, due to their negligence!!!
The first authorization 10/10/17 was denied with stipulations:
1- updated mri
2- physical therapy or another conservative therapy, in which... I had the trial spinal stimulator july 2017
3- I was smoking
4- my bmi was too high

The second authorization was submitted 11/14/17 with updated compliance:
1- updated mri
2- physical therapy and proof of spinal stimulator trial (conservative therapy)
3-documented proof of quiiting smoking 10/11/17
4- documented proof of lowered bmi

Both authorizations by a very credible surgeon that has been voted the #1 surgeon several times. Both peer to peers have been denied also.
I have 2 rods in my back, I have been dealing with this for a year, I live in pain every day, I am not able to walk stores or any amount of distance without severe pain. I substituted a few times during the summer and cried in pain as I walked the children from the class to the cafeteria. I can't do art shows, theme parks, hold my grandchildren, or get on the floor to play with them.

Florida blue's decision baffles me and I will not give up!!! I will go as far as I can. This is happening to too many people.

This will be reported to every social media there is!!!

  • Updated by Donna Zerlin · Nov 28, 2017

    Florida blue denies all authorizations for surgery and surgeon's peer to peer twice!!! I will be contacting every social media outlet there is to let everyone know about florida blue!!!

    Please help! I am disgusted and heart wrenched over the guidelines and protocol of florida blueinsurance company. I am also baffled that florida blue insurance company can deny a request by a doctor regarding a patient's care. The following is an explanation per our telephone conversation. My surgeon, dr. Devin datta's office put in a request to bcbs for me to have back surgery on 10/18/2017. On or about 10/11/2017, I was informed by dr. Datta's office that bcbs denied my surgery. I was also informed that every patient that has gone through their office with this insurance has been denied for some reason or another. Dr. Dattascheduled a peer to peer, which was also denied. I contacted bcbs myself several times before I was able to get answers. At first, I was told that it was approved, I was given a reference number, codes, and dates of service. After contacting dr. Datta'soffice back, they informed me that the codes and authorizations that were given were for the hardware that was going to be used in my surgery. After contacting bcbs again and asking for a supervisor, I was connected with jennifer trout. Jennifer told me that the surgery was denied due to: my bmi being a little too high, I was smoking cigarettes at the time, and I did not have an mri, physical therapy, or injections in the last 6 months. I explained to jennifer that I had back surgery in 2013 and 1 in 2014 and had 2 rods in my back already. Last year before my visit with dr. Datta, my neurologist ordered a ct myelogram, which is an extensive test showing results or damage around the hardware in my back and previous surgeries. It took me 5 months to get into dr. Datta's office. I had therapy last year before I went to dr. Datta and the ct myelogram.in july 2017, I had a spinal stimulator trial put in my spine with the hopes that it would work and I could avoid surgery. Spinal stimulator: a type of implantable neuromodulation device (Sometimes called a "pain pacemaker") that is used to send electrical signals to select areas of the spinal cord for the treatment of certain pain conditions. Scs is a consideration for people who have a pain condition that
    Has not responded to more conservative therapy.
    Unfortunately, it did not work. I have been out of work since last november, no income whatsoever, homeless (Staying at a friend's house for now), and I have $75 copays every time I go to therapy or surgeon. My help from people is running out.
    In my last conversation with jennifer, she told me that the surgery was denied due to: my bmi being a little too high, I was smoking cigarettes at the time, and I did not have an mri, physical therapy, or injections in the last 6 months. I have complied with everything. I had an mri, my last cigarette was october 11, 2017, I have been to therapy a few times which is not helping, my bmi is lower, because the weight the doctor's office had was the weight I gave them 265lbs. I actually weigh 249.5 lbs at the present time. I also had the spinal stimulator trial, which would be considered another "conservative therapy" before surgery. I had an appointment with my primary doctor, so everything is documented. If I need to be tested for nicotine, I have no problem complying, but I continue to wear the nicotine patch.

    Last week, my surgeon's office resubmitted a request with updated compliance for authorization for the same surgery on levels l2-l3 and l5-s1. The surgeon's office contacted me to inform me that florida blue is now approving l5-s1, but is denying surgery on level l2-l3. This morning, I contacted customer service once again, only to be told that they have more stipulations.

    The surgeon's office said they have denied surgery for almost every patient on the same insurance. How can they get away with this?

    Please help!

    Sincerely,

    Donna zerlin
    D. O. B. 12/29/1967
    [protected]

Responses

  • O
      Dec 16, 2017

    Hopefully this will help. When arguing with an insurance you have to know what they are looking for. Surprisingly, many offices don't think to look at the medical policies. Florida Blue's at General Medical Policy can be found at: http://mcgs.bcbsfl.com/. Then in the left hand column you want surgeries and then you want Lumbar Spinal Surgeries and it will tell you their criteria. It is stated in the policy that you have to have stopped using tobacco at least six weeks prior and you cannot be morbidly obese. They do not define morbid obesity though. Typically morbid obesity is a BMI of 40 or greater or a BMI of 35 or greater if you have other complicating health issues like diabetes, heart disease, etc. If your BMI falls under that then your provider needs to find out WHAT their definition of morbid obesity is. If FB is saying you are morbidly obese because your BMI is like 38 and you DON"T have a co-morbidity (like diabetes or heart disease) then your doctor needs to point out to them that by their own position statement for bariatric surgery they (FB) define morbid or severe obesity as BMI greater than 40 in patients without other co-morbid complications so by their own definition you cannot qualify as morbidly obese.
    The medical policy lists all the various CPT codes and it will tell you which ones they consider "investigational" Investigational is a whole different thing to argue.
    I don't think the spinal stimulator counts as "conservative" therapy in their books. The doctor needs to be specific when he does the PA. Either proof that you've done their required criteria or clinical reasons why you cannot. For example: Say 34 year old woman with a BMI of 36 with Type 2 diabetes needs spinal surgery. I would say something like: Spinal surgery is medically necessary for Ms. Doe. She has a three year history of spinal issues with previous spinal surgeries done in 2013 and 2014. Her condition is impacting her daily activities. She cannot sit for very long periods of time and therefore has been unable to work. She is currently unemployed and living with a friend. This condition has been on going since 2011. She previously tried treating with NSAIDS and physical therapy prior to her surgeries in 2011. I do not have documentation of that because it was through another provider but it is something her insurance required prior to surgery at that time as well. The pain she is under is making it difficult to control her diabetes. She is currently not a candidate for steroid treatment or NSAIDS because steroids would complicate her glucose control and NSAIDS could be damaging to her kidneys, particularly in the presence of her diabetes. Good glucose control is critical to her recovery. As far as her BMI is concerned, I appreciate that morbid obesity can hinder her ability to heal but we are talking about a difference of 1. Please provide me with the clinical data that shows that a BMI of 35 is going to vastly improve her surgical outcomes over a BMI of 36. The consequences of not doing surgery is far more detrimental.
    That is just a very rough brief example of what you have to do. Either specifically meet or explain 0why you can't meet each thing they are looking for. t's kind of like a debate. If you don't meet their criteria you have to be able to refute their opinions with solid evidence. Hopefully that helps...

    0 Votes
  • O
      Dec 16, 2017

    Oh, I would also ask, in your case specifically how they determine that the hardware is medically necessary but the surgery to install what they have agreed is medically necessary isn't authorized. That is like a car manufacturer saying that the transmission on your car is covered under warranty but the labor to install it is not authorized. Dumb...

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