I've lost my fight for approval

November 3, 2000

To my list-mates & friends,

It is with deep sadness, frustration and confusion that I write

to inform you that BCBS of Michigan has again denied authorization

for surgery. I worked so hard to win this appeal. I gave them proof

that they had paid for another patient's surgery with the 43847 code

but in the end they say that doesn't count because she had her

surgery in California and BCBS of CA paid for it and then were

reimbursed by BCBS of MI. I argued that to me that was the same as

if they had paid it directly but they just don't see it that way.

They told me they are sending Dr. a reply to his appeal letter

to inform him of the denial. I told them they were discriminating

against me and that I didn't see how they could live with themselves

since they had no ethics. The woman had the nerve to tell me that I

shouldn't be so harsh on them and that if I really needed this

surgery so bad that my surgeon should be willing to operate on me to

save my life whether he got paid or not! I just blew up at that and

told her that I was paying THEM to cover my surgery and that a doctor

is a doctor, not an insurance company.

I am at a loss now as to where to turn. I know I can sue but I

don't know if I have a chance of winning. I know Walter is a good

attorney but I haven't been able to find out from him if he feels I

have a worthy case or not. I know that if it costs $300-$500 for an

attorney to handle an appeal letter then lawyers fees to sue are

probably in the thousands and most wouldn't be interested in my case

because they couldn't get money out of BCBS since my insurance is a

self funded plan. All they could win would be the cost of my surgery

and court fees but no punitive damages. I have given this my

everything and have never been through a longer 6 months in my life

than the past 6 months of intense battle with BCBS of MI. I cannot

self pay, don't have a retirement savings to take it out of and I do

not have any wealthy family or friends who can help so it looks like

I am at a dead end here. For all who are having to fight like I

did...don't let my defeat get you down. Many others win their

appeals so have faith that you can win too. Thanks for the

shoulders of support over the past year and a half on the list and if

a miracle happens and I get to have surgery I'll let you know.

Sheila H

Texas

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