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Blue Cross Blue Shield (of Massachusetts) (Read 3816 times)
Kathymc
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Blue Cross Blue Shield (of Massachusetts)
Jul 11th, 2012 at 4:24pm
 
Hi everyone, I hope you can help me. My Neurologist here in Boston received a response from Dr. Steinberg in California that we was willing to evaluate me and provide treatment in California. I have a couple of problems. My doctor here has never been for the bypass surgery (had a bypass of left side, now will need it on the right). I have done the last 2 years after surgery with "medicine" treatment to increase blood flow, which has not worked. Our rep for my husbands BC/BS said that it will be a very hard uphill battle to even get BC/BS to consider anything to be done out of state. (I also have medicare which I know does not pay for this ailment.)
For those of you who have been through this what is the best way to approach the insurance company? Should Dr. Steinberg, my Doctor in Boston and my local primary Doc be the ones writing to the insurance, she would also?

I would love to hear from those of you who have had this battle, and what the outcome was.

Thanks everyone in advance,

Kathy
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momkaren
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Re: Blue Cross Blue Shield (of Massachusetts)
Reply #1 - Jul 14th, 2012 at 11:11pm
 
Hi Kathy,

My 13 yr old son was diagnosed with Moyamoya last yr. We live in Philadelphia, Pennsylvania and had surgery done at the Childrens Hospital in Boston.

My son is covered by 2 different ins companies, (both are under Blue Cross) Keystone Health Plan East which is from my husbands works, and Keystone Mercy which is medical assistance from the state. My son has multiple disabilities.

We "battled" with Keystone Health Plan East for 3 weeks, went through 3 appeals, had my son's pediatrician and the neurosurgeons from Boston involved, and he was denied coverage each time. Since this is his primary insurance, we had to go through them first and we assumed his medical assistance would surely deny coverage also, that is why went through appeals. BUT, shockingly, his medical assistance did approve and cover everything!

The reason the main insurance denied coverage was because there was a neurosurgeon in my area (in network) that was able to perform the surgery. This was true, but we wanted to have the surgery done by experts in this field. Medical assistance never questioned anything.

I also must tell you, even though medical assistance covered everything he first time. My son ran into many complications and we were back in Boston a few times over the summer last year and now we are being billed for medical expenses for a couple of these visits!

Is there an experienced surgeon in your area? If not, you should not have a problem with them approving coverage. Have you spoken to anyone from medicare about this?

Karen
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Kathymc
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Re: Blue Cross Blue Shield (of Massachusetts)
Reply #2 - Jul 18th, 2012 at 12:22am
 
Karen,

Thank you for your response. I actually live in Massachusetts. My left bypass was done at Brighams and Womens by Dr. Day but he has since left and Dr. Du who has replaced him (and assisted him in my original surgery) has stated that there is nothing else she can do. There is also Dr. Oglive at Mass General who treats MoyaMoya patients but what is assistant described doing to me is really only done in children and has little effect on adults. We have yet to contact medicare but I know in the past that they have never covered moyamoya items, in fact they did not cover my latest MRA that was done stating that it was a test that did not to be done as it was not necessary for it to be done.
Dr. Steinberg has looked over my case and has agreed to evaluate me and treat me. I not only have Moyamoya on both sides but the "watershed" in the center of the brain is blocked also. The doctors in Boston have said there is nothing they can do for me.

Again, thanks for the response, and I hope things work out for your son and his treatments in Boston. Dr. Scott is the best around for children with Moyamoya.

Kathy
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Megan miller
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Re: Blue Cross Blue Shield (of Massachusetts)
Reply #3 - Jul 20th, 2012 at 4:33am
 
Thank you..I was just trying to get my taxes done before the 1099 came in the mail. I will call BCBS.Thanks for your help.
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momkaren
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Re: Blue Cross Blue Shield (of Massachusetts)
Reply #4 - Jul 24th, 2012 at 9:54pm
 
OMG, why can't the dr who assisted in your first surgery do the same for the other side? That's crazy! I know there is a different surgery for adults, it would make no sense for you to have this done. Couldn't Dr. Scott and Dr. Smith recommend someone else in your area?

If there is really no neurosurgeon in your area, how the hell can the insurance deny coverage "out of network" when your life depends on it!!!! That is scary! I would go ahead and try to have it approved. If it is denied, make an appeal! Contact your local media, newspaper, etc. My son was denied coverage by his primary insurance because there is a surgeon here that could have done it, I just didn't want him too.

I will keep you in my prayers. Best wishes and I sure hope you can get this straightened out and approved!

Karen

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Kathymc
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Re: Blue Cross Blue Shield (of Massachusetts)
Reply #5 - Jul 25th, 2012 at 1:44am
 
Thanks Karen. There is another Doctor in Boston at Mass General who does the bypass surgery but he has never dealt with the middle brain watershed shed problem. We are in the process now talking to BC/BS so I'm praying for the best result possible.

I hope things go well for your situation with your son and you are in my prayers also.

Best,
Kathy
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