I remember watching the Julia Robert’s movie, Erin Brockovich and thinking how is it possible for that insurance guy to be able to go along with that memo/mandate from the powers that be and deny patients their health coverage?  Then, this past year the very same thing happened to my sister.  She suffers a congenital degrading disc thing in her back.  She is a fit, previously healthy 29 year old.  She had a discetomy in her lumber region when she was in high school.  Since then she has lived with continuous back pain.  She has seen specialists all over the Chicagoloand area.  She continues to suffer extreme pain.  Finally, her main specialist suggested a fusion.  This would be a major operation and require pre-authorization.  BCBS-IL denied her because she had not attempted other means of fixing the pain.  Her previous discetomy was too long ago to be considered a viable attempt at fixing a “degenerative” situation.  So, in December she had another discetomy and recovered to only a slight amount of relief.  I now blame BCBS-IL for basically turning my otherwise healthy younger sister into a near Vicodin addict.  She has been popping major pain pills for almost a year now.  And now, NOW, BCBS-IL finally approved the fusion surgery because the various specialists all determined that the discetomy was not a viable treatment option for a condition that will only continue to get worse with time – as the “degenerative” label so obviously suggests.  So, until the fusion surgery she will continue to pop the Vicodin just to grit and bear it.  She has talked to lawyers and sought an outside review of the whole situation, but her situation has been resolved with the scheduled date of the operation.  Now she faces an even more interesting situation since the “spinal” issue will flag her for future insurance plans and thus cost her more.  The method of how BCBS-IL handled her case is just one example that completely frustrated her (and our family).  It coincides with my own.

I was denied for Surgical Treatment for Morbid Obesity.  Let me update this whole thing because I am not HUGE, but I am obese by BMI standards and having R.A. makes working out something that helps to combat joint stiffness, but doesn’t necessary allow me to attack flab with the gusto that I once enjoyed so much.  I looked into this two summers ago and began jumping through all of the BCBS-IL hoops toward approval.  Two years ago I was also a cardiac patient as a congenital heart condition came to light at the same time as my diagnosis with R.A.  Actually it was the chest pain that got the whole health assessment ball rolling.  The cardiologist suggested a follow up appointment with a rheumatologist and the rest is history: LBBB, R.A., and hypothyroidism.  That was a fun year: 2008.  I wasn’t really THAT overweight in 2008, I had previously lost a lot of weight in 2007 due to my obsessive working out that I did to cope with mourning a death.  I just thought that I was sore and my family was worried that my massive weight loss, combined with pain, was something heart related – especially since our family has heart issues on both sides.  Anyway, as 2008 hit me with all the medical woes, the working out scaled back and almost stopped, with the rare exception here and there.

With the slide into unhealthiness and the mental shock of dealing with a diagnosis of R.A. – the same disease that has possessed my mom – I was not the most motivated patient when it came to hitting a treadmill or lifting weights.  If I did what I used to be able to do with such little effort, I would be so sore and so stiff that I could barely function the next day.  I wore magnetic bracelets, sought Eastern therapies, and began to discover what life with R.A. was really like.  I had been heavy, then fit, then fat, then less fat, then really fat, then just mushy….all my life going up and down the scales and clothing sizes.  All my life I had done one thing or another to address my body composition.  Finally, the rheumatologist suggested that I look into Lap Band.  Getting all and any extra body weight off my sore joints was hugely important.  So in 2008 I attended an informational meeting about it.  There seemed to be so many insurance hoops to clear just to get to the point where they could submit to insurance.  I didn’t have the time and I really didn’t have the money.  So I continued to attempt diets.  The bariatric doc from 2008 suggested that I see another doc who prescribed the OptiFast diet.  I’m not sure how many readers can ever, ever say that they sustained a long-lasting success using this p.o.s. plan.  I did the weekly weigh-ins, meetings, and extra vitamin shots (those weren’t free either).  This was all very expensive, but I sucked it up because it was a “non-surgical” treatment.  I starved on that program, had migraines, flare-ups, and all kinds of digestion problems.  So I stopped because I couldn’t continue to feel like crap from doing that.

I had acupuncture.  I had a permanent pin in my ear in order to “curb” my appetite.  By the way, the acupuncture was super helpful, and of course, since it was able to actually relieve my R.A. pain (I mean “relieve”) it was not covered by BCBS-IL, so I became poorer in my paying out of pocket for it and then had to give it up since I just couldn’t do it because of cost.  Nonetheless, I continued to gain weight and hurt.  The vicious spiral or R.A. and weight….it hurts to work out, so you don’t, so you get heavier, you hurt more, you become even more sedentary.  Last January (2010) I finally resolved to see out the bariatric surgery option, really as a last resort.  My surgeon said that I should have no problem getting it covered because of my BMI and the co-morbid condition of R.A.  Well, if only it was that easy.

I began to work with my new PCP who not only was the THIRD doc to explicitly recommend The South Beach Diet as part of my “medically supervised diet” but who also addressed the heart related issues that I needed to have monitored.  BCBS-IL paid for these monthly appointments, the mandated pulmonary and gastric testing, and other appointments with specialists as part of the pre-op process.  There was a sleep study and an upper-GI – these exams are by no means cheap, and BCBS-IL paid them.  Then, as the scheduled date for surgery approached I received a letter to say that my coverage was denied due to two reasons.

The first reason is crazy.  They claim that I have not documented that I am 18 or older.  I’m sorry – every doc’s note shows my birthdate on it…are they kidding????

The second reason states that I have not attempted appropriate non-surgical treatment!!!  What?!  Come on BCBS!  They want to see a medically supervised diet!  Didn’t I just do that?  But they wanted Weight Watchers, NurtiSystem, or Jenny Craig.  That is nuts!  The South Beach Diet was recommended by THREE different doctors.  Am I supposed to be doing a “medically supervised diet” that goes against what a medical practitioner says to do so that I can go to a strip mall store front and check in with a part-time customer service agent?  Give me a break, BCBS-IL!  You are purely playing a numbers game and denying me the procedure because you think that you can.

I’m going to fight!  I pulled together the 54 pages of the previous submittal and re-submitted with a cover letter that outlines the points of their contention.  My PCP wrote a letter stating the “medically supervised” part of the process.  I just heard today that BCBS-IL turned it down again.  The date was set for July 19th, is now pushed back to July 26th.  It looks like it might be pushed back to December now since they want me to do Weight Watchers.  I intend to get this in the calendar year 2010 since I don’t want to have to go through paying my deductible all over again – which is probably a factor that they have considered.  What a nasty numbers game!

So I surfed the web to see what other factors were going on with BCBS and was shocked to see what a large number of consumer complaints there are.  I’ll begin by saying that their pre-authorization procedures for my case (and for my sister) are ridiculous!  I can’t also begin to express my absolute and utter DISGUST at their automated phone system.  Their help line needs help.  They will not pass me along to anyone who can do more than simply restate what was in a letter or what the plan states.  They don’t HEAR you, they don’t LISTEN.  BCBS-IL will find any way it can to keep the BIG MONEY that it gets paid.  It is all about profits.  It is rather sad that people’s hard-earned cash gets funneled into this system that makes it impossible to get the coverage when it logically makes sense to provide it.  Hanging up coverage on a tiny technicality here or there, forcing my sister to have an operation that the specialists knew would not do a thing for her, just because the damn insurance company wanted to see that procedure first, is inhumane.  She suffered pain, loss of time from work and family, and a year of her young life to pain.  Their system, that she, me, you – all of us pretty much have to fund FAILED.

Just to make things all the more disgusting, try this.  Do a web search of BCBS CEO’s salaries.  Their salaries aren’t nearly as shocking as the “bonuses” and “payouts.”  There are fat-cat corporate dudes getting rich because of my monthly paycheck deductions.  Yet, I have to continue to jump through hoops for some company that can fly their execs around on Leer Jets!?  Unbelievable!

I’m going to the Illinois Insurance Reform Group’s site and seeing what my next steps are.  I’m going to ask BCBS-IL to do a peer-to-peer review.  I am also going to have an outside review too.  I’d love any thoughts/ideas/suggestions for how to get some actual answers from someone who can actually do something.