Below is my Level 3 Appeal which is a request for an External Review. As you can see at the bottom of the letter I carbon copied more than 30 individuals on my appeal. I included a separate cover letter for all of these individuals and included the image of Lily that you see at the top left hand of your screen. I felt that it was important to put a face to the story.
December 17, 2009
Vicki Roberts, R.N.
Medical Appeals and Grievances Coordinator – External Review A116
BCBSAZ
PO Box 13466
Phoenix, AZ 85002-3466
RE: Elizabeth Langford
Plan ID #: ——-
Group #: ——-
Claim #: Multiple
Account#: Multiple
Dear Ms Roberts,
I am writing to you in response to a Level 2 Standard Formal Appeal letter of denial that I received from you on November 24, 2009. I am requesting a Level 3 External Review by an external IRO as I believe my claims regarding a medically necessary cesarean section that was preformed by Dr. Sara Giali fall within the scope of medical necessity.
I was admitted to the labor and delivery ward of Mercy Gilbert Medical Center on Sunday, August 9, 2009. It was determined that I was in active labor and after receiving an epidural and reaching full dilation of ten centimeters I began to push. After pushing for an hour and a half my OBGYN, Dr. Sara Giali recommended that we proceed with a medically necessary cesarean section. Dr. Giali explained to me and three other people in the delivery room that a cesarean section was medically necessary to deliver my baby in order to pre-empt potential damage to the baby or to me.
Dr. Giali indicated that my daughter, Lily was exhibiting non-reassuring fetal heart tones and was failing to descend and that a cesarean section was “medically necessary.”
Dr. Giali performed a medically necessary cesarean section on August 10, 2009, delivering my daughter Lilian Belle Cobo at 5:05 am on Monday, August 10. I have included the statement of medical necessity from Dr. Giali with this letter along with the doctor’s notes from the labor and delivery. It is my belief that BCBSAZ should accept Dr. Giali’s professional determination of medical necessity and provide coverage for my cesarean section and related claims.
After my husband and I purchased our policy in May of 2008 the “Complications of Pregnancy” and reasons for cesarean sections to be covered were significantly changed by BCBSAZ. It is my belief that the narrow parameters for which BCBSAZ will now cover a cesarean section are too limited and not in the best interest of their policy holders. The new guidelines do not take into account fetal distress and as a parent I cannot imagine what could be more “medically necessary” than to deliver a baby that is experiencing fetal distress and exhibiting non-reassuring fetal heart tones as quickly and safely as possible.
It seems reasonable that a doctor of obstetrics is better qualified than an insurance company to make a decision as to what is or is not “medically necessary.” In a critical moment when my doctor is providing me with serious medical recommendations my concern and focus should be on what is best for my child and me, not what my insurance company will cover because of terminology or a matter of technicality. I pay my insurance company for insurance coverage not for medical advice and I was devastated to learn that BCBSAZ had no intention of covering my cesarean section and related claims even though it was clearly medically necessary.
I never had any intention of having a cesarean section. As our policy with BCBSAZ did not include maternity, my husband and I followed the advice of our insurance broker that sold us BCBSAZ policy and paid up-front, out-of-pocket for all of our pre-natal care, pre-natal ultrasounds and pre-paid our hospital for a vaginal birth, epidural medications and 48 hours of post-partum care. In total we paid $8,000 out-of-pocket prior to the baby’s delivery in August. We paid $2,750 for pre-natal care and ultrasounds to Valley Women for Women, $4,250 to Mercy Gilbert for their self-pay pre-paid vaginal delivery package and $1,000 to Mercy Gilbert Medical Center’s contracted anesthesiologist group for an anesthesiologist to administer an epidural during delivery. My husband and I understood that our plan with BCBSAZ did not cover normal maternity or delivery but believed that in the event we had no other option but to have a cesarean section out of” medical necessity” that our plan would cover the cesarean section and related claims.
Had we wanted a cesarean section we could have requested that our doctor perform one and we would have paid an additional amount of money, approximately $1,000 to Mercy Gilbert Medical Center and would have had a scheduled cesarean section delivery. We did not pay the additional money because we believed that our plan with BCBSAZ would cover a “medically necessary” cesarean section. It was only after our delivery that we learned that BCBSAZ did not believe that “non-reassuring fetal heart tones” or fetal distress is a not a complication of pregnancy and does not make a cesarean section “medically necessary.”
My daughter is now a little more than four months old and I am continuing to loose precious time that I should spending with her, because I am instead spending it filing multiple appeals with BCBSAZ and speaking with representatives from Catholic Healthcare West asking them to place a hold on our outstanding accounts. As a self-employed person my freelance business as a graphic designer and internet marketing manager is now suffering because continuing to file appeals and manage my accounts with the hospital takes valuable time on a weekly basis that I should be spending on earning an income to help with my family’s living expenses.
In denying my claim for a cesarean section that I believe any reasonable person would see as medically necessary to pre-empt serious medical complications and even the possibility of death for my daughter and me, it is my belief that BCBSAZ has acted in bad faith.
It is also my belief that BCBSAZ has not communicated with me in a clear manner. The denial letter that I received from BCBSAZ dated November 24, 2009 stated in the header that it was addressing “multiple claims” and then noted that it was upholding it’s decision to deny the claims related to a July 24, 2009 OB triage observation services and August 9, 2009 primary cesarean section services. Upon further inspection I found that multiple parties had been carbon copied on the letter including Dr. Quentin Chan the anesthesiologist present during the labor and delivery that administered my epidural and Richard Lease the RNFA present during the cesarean section. The letter from BCBSAZ indicated that they were upholding the denial of the “August 9, 2009 cesarean section, hospitalization and related services.”
I feel that grouping the other two claims from Dr. Chan and Richard Lease into one denial letter and not clearly designating them apart from the August 9, 2009 primary cesarean section is unfair, unclear and another example of BCBSAZ acting in bad faith. Had I not identified that these other two claims were being grouped with the cesarean section claim I might have missed my opportunity to appeal those claims within the designed 30 day period. While I understand that the claims were related, I submitted an individual appeal for each claim that was individually post marked and I believe that BCBSAZ should have extended me the same courtesy.
It is still unclear to me which appeals the letter I received from BCBSAZ dated November 24, 2009 is responding to. The letter clearly mentions claims for July 24, 2009 and August 9, 2009. This would lead me to believe that the other claims I appealed have been overturned in my favor. If however BCBSAZ intended that the letter dated November 24, 2009 be a comprehensive response to all of my appeals I ask that this letter, dated December 17, 2009 act as a request for a comprehensive Level 3 External Review of all my appeals filed with BCBSAZ in 2009.
This review should include an appeal that I submitted to BCBSAZ for a well-woman exam that was performed on December 31, 2008. My benefit plan clearly covers an annual well woman exam and being pregnant should not negate my right to that exam nor hold BCBSAZ exempt from paying their responsible portion.
I believe that denying my well woman exam claim is another example of BCBSAZ not applying careful consideration to my claims and once again acting in bad faith.
The other appeals that I filed were for claims from pre-term OB Triage visits in July and August of 2009. As it was my understanding that BCBSAZ would cover a medically necessary cesarean section, it was also my understanding that pre-term labor was considered a complication of pregnancy and would also be covered in the event that I experienced pre-term labor that required medical treatment and observation.
In reference to the cesarean section claim and related claims, my doctor and I acted in my best interest but most importantly my child’s. My cesarean section was not done out of laziness, a lack of motivation to continue to push, convenience or any other reason besides what was medically necessary to ensure that my daughter was delivered healthy. It is my belief that any parent would have done the same.
The alternative to having the cesarean section could have been devastating and potentially life threatening to both of us. What could possibly be more medically necessary than that? Had I not followed my doctor’s recommendation my daughter could have been born with any number of types of physical and/or neurological damage, resulting in lifelong numerous claims filed with her medical insurer, BCBSAZ.
I am asking BCBSAZ to reverse their previous denials and pay their portion of all of the claims associated with the cesarean section that my doctor performed out of medical necessity on August 10, 2009. In an effort to be absolutely clear about what claims I am appealing I have listed the claim numbers below. Thank you for your time and assistance in this matter.
Sincerely,
Elizabeth Langford
Claim Numbers Being Appealed
- XXXXXXXXXXX3900 – Provider, Richard A Lease RNFA ($1,725.00)
- XXXXXXXXXXX2400 – Provider, Mercy Gilbert Medical Center ($17,454.70)
- XXXXXXXXXXX9600 – Provider, Quentin Chan MD ($3,561.60)
- XXXXXXXXXXX5300 – Provider, Laboratory Corporation of America ($341.00)
- XXXXXXXXXXX8100 – Provider, Mercy Gilbert Medical Center ($2,073.98)
- XXXXXXXXXXX8100 – Provider, Mercy Gilbert Medical Center ($1,531.33)
- XXXXXXXXXXX8900 – Provider, Chandler Regional Hospital ($3,405.60)
- XXXXXXXXXXX2000 – Provider, Valley Women for Women ($3,774.00)
Enclosures:
- Statement of medical necessity for cesarean section from Dr. Sara J. Giali
- Operative Report from Dr. Sara J. Giali
cc:
Arizona Department of Insurance
Sara J. Giali, D.O.
Mercy Gilbert Medical Center
Denise Belise, M.D.
Richard Lease, RNFA
Mia Van Eken, D.O.
Quentin Chan, M.D.
Heather Wunderle – JDH Insurance
Amy Anderson – Patient Financial Services for Catholic Healthcare West
Michael O. Adkins, MD – At-Large Director of the Arizona Medical Association
Suresh C. Anand, MD – Maricopa Director of the Arizona Medical Association
Dr. John H. Crothers, MD – At-Large Director of the Arizona Medical Association
Howard B. Fleishon, MD – Maricopa Director of the Arizona Medical Association
Philip E. Keen, MD – At-Large Director of the Arizona Medical Association
Sheldon P. Kottle, MD – Maricopa Director of the Arizona Medical Association
Marilyn K. Laughead, MD – Past President of the Phoenix Obstetrical & Gynecological Society
William R. Martin, III, MD – Maricopa Director of the Arizona Medical Association
Rober Orford, MD – Vice-President of the Arizona Medical Association
Beth A. Purdy, MD – President of the Arizona Medical Association
Carol S. Taylor, MD – At-Large Director of the Arizona Medical Association
A. Judson Tillinghast, MD – Maricopa Director of the Arizona Medical Association
Robert O. Wilson, MD – At-Large Director of the Arizona Medical Association
Kelly Pile – Executive Director of the Phoenix Obstetrical & Gynecological Society
Michael Hibner, MD – President of the Phoenix Obstetrical & Gynecological Society
Gerald F. Joseph Jr, MD – President of the American Congress of Obstetricians and Gynecologists
Congressman Jeff Flake – U.S. Congressman for Arizona’s Sixth District
The Arizona Medical Board
Dr. Douglas D. Lee, M.D. – Arizona Medical Board Chair
Terry Goddard – Arizona Attorney General
Jan Brewer – Arizona Governor
Todd W. Van Sant – President of the Arizona Insurance Claims Association
Jon Kyl – United States Senator, Arizona
John McCain – United States Senator, Arizona
