BCBSTN Denies Sleep Apnea Surgery

Your doctor asked us to decide if 30520 Septoplasty, 30140 Submucous resction inferior turbinate, 42826 Tonsillectomy for treatment is covered by your health plan.

Based on the terms of your health plan, BlueCross BlueSheild of Tennessee did not approve the predetermination for:

septoplasty and Submucous resection inferior turbinate indicated for nasal obstruction when patien has received maximum medical treatment for symptoms and tonsillectomy is indicated when concurrent uvulopalatopharyngoplasty is being proposed for treatment of tonsillar hypertrophy and mild sleep apnea.

So, I just received the above letter. I haven't spoken to the doctor/hospital, yet going to the best 'hospital' in Middle TN. The doctor told me I would getting the UPP surgery and a septoplasty.

Any way I could an appeal? My deviated nasal spectum is actually from a car accident, and the surgery I had, I guess didn't correct it fully ten years ago.

They also state I have mild sleep apnea, when it is actually severe sleep apnea.

Or would I not have a chance at an appeal.

Your denial letter should have a description on how to appeal. However, based on our experiences with appeals to Anthem BCBS, do not expect a good result. They will make any excuse that they can dream up to reject your appeal. They will makeup false medical facts and do whatever it takes to get you off their backs. IMO insurance companies make used car salespersons and lawyers look good. Sorry for the negative response, but I just got ObamaCared again yesterday for next year so I am more down on insurance companies than normal. I hope you have better luck than we have had with your appeal.

Wow. That doesn't even make sense. I'm a lawyer and I can't figure out what they are trying to say there.

One problem is that UPP isn't widely regarded as effective for treating sleep apnea. The opinions I've read, heard and seen here is it's a lot of pain for not a lot of gain in that regard. However, it's quite possible that you need the treatments proposed for completely unrelated and completely legitimate reasons. It might be better in formulating an appeal to stress those reasons rather than sleep apnea.

Have you asked your doctor whether they have dealt with this before? They might know the right "magic words" to say to get the treatment through. If you can find an attorney down there who is familiar with this insurer's procedures, possibly having the attorney write a letter might help.

Good luck and feel better.

Be careful because most appeals are time sensitive. The denial should tell you what your appeal rights are and how to appeal. Try to get your doctor's office to help--as pointed out "they know the magic words."

It looks to me like the denial is based on two issues:

1. That you haven't tried other therapies "sufficiently" ("maximum medical treatment for symptoms") first. You will need your doctor to document other things you have tried, and why they aren't working for you. If you have good treatment with CPAP, that MAY be the basis for their denial--just guessing.

2. That there are very specific criteria for tonsillectomy (" only when uvulopalatopharyngoplasty is being proposed for treatment of tonsillar hypertrophy and mild sleep apnea") and it may be that the documentation doesn't support that you have "tonsillar hypertrophy" (big tonsils) with mild sleep apnea. They may limit the procedure to people with mild sleep apnea because it's not as effective for severe sleep apnea--I don't know, just guessing.

Anyway, the doctor's office may help you by submitting additional documentation addressing the identified criteria.

Have you thought these procedures through carefully--understanding that they can cause severe pain and lifelong side effects and may not get you off CPAP? Do you understand what your doctor's definition of "success" for these procedures is (typically it's a REDUCTION in AHI or pressure needs, but that doesn't mean necessarily that you still won't need PAP).

If you are determined to get these procedures, then it's worth appealing. You have a good chance of success if your doctor will help with good documentation of need based on their criteria.

The "Blues" have pulled enough scummy tricks on me that they are permanently off any list
for my consideration for Medicare supplements.
Once bitten, forever shy.

NashTrat wrote:

Your doctor asked us to decide if 30520 Septoplasty, 30140 Submucous resction inferior turbinate, 42826 Tonsillectomy for treatment is covered by your health plan.

Based on the terms of your health plan, BlueCross BlueSheild of Tennessee did not approve the predetermination for:

septoplasty and Submucous resection inferior turbinate indicated for nasal obstruction when patien has received maximum medical treatment for symptoms and tonsillectomy is indicated when concurrent uvulopalatopharyngoplasty is being proposed for treatment of tonsillar hypertrophy and mild sleep apnea.

So, I just received the above letter. I haven't spoken to the doctor/hospital, yet going to the best 'hospital' in Middle TN. The doctor told me I would getting the UPP surgery and a septoplasty.

Any way I could an appeal? My deviated nasal spectum is actually from a car accident, and the surgery I had, I guess didn't correct it fully ten years ago.

They also state I have mild sleep apnea, when it is actually severe sleep apnea.

Or would I not have a chance at an appeal.

You do NOT want to get a UPP or UPPP. They're mostly ineffective for treating sleep apnea.


Den

.

Dit toh!

I got my surgery approved with an AHI 8 (haven't received the bill yet, ha) Insurance is ok with it. Tell them you can't tolerate the cpap anymore and it's your only alternative.