Denied as “self referral” from referred doctor.

BCBSTX(hmo marketplace as we are 1099) has denied a claim for a breast reduction stating it was “self referred” as in it was a doctor of my choice with no referral from my pcp and explained this is an excluded benefit unless medically necessary. My pcp did refer the plastic surgeon and BCBSTX approved it before my consultation. I have all of this in letters/writing/messages through the system. I called bcbs and was told to submit an appeal.

My pcp sent in the appeal on my behalf (plastic surgeons original letter with measurements and pictures, additional pictures, notes from my neurologist showing I have lesions from migraines (caused by tension and strain) and a letter of medical necessity and asked for it to be expedited due to pain. After a week, I called bcbs and was told it was again denied and asked to have my doctor set up a peer 2 peer. My doctor (who is closing her practice Friday) offer to do a p2p but when she called in to schedule was told it was not denied but was closed because it was opened in error and I should have never been able to appeal. I called to verify this and they told me yes, this is correct and it was a finally ruling so I can’t do a p2p and I’m just out of luck. They suggested I start the process over and it “might” get looked at but probably not.

I feel like bcbs labeled this incorrectly as a self referral from the beginning since there was a letter of medical necessity included and then had me do a laundry list of things just to tell me it did not matter at the end and I wasted my time. I’m at a complete loss and am having a hard time mentally and physically dealing with this. I’m hoping someone might have advice or at the very least let me know who to file a complaint with.

submitted by /u/PartlyCloudyTomorrow
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