Back in February 2019 I had a colonoscopy done because of family history of Colorectal Cancer at an early age, I am a 28 year old male. Back in December 2018 my brother who is 29 was suffering from rectal bleeding and had a colonoscopy done. They found a Pre-Cancerous Polyp and removed it. The Doctor recommended for me to get checked out since I am a first degree relative. Thankfully nothing was found. This is my first time having medical insurance and it has been a nightmare for me.
Since my colonoscopy was done Blue Cross and Blue Shield of New Jersey (I live and work in Connecticut but my employer, TD Bank, is based in New Jersey) has been denying responsibility for payment and claiming it wasn’t a medical necessity and that I had to pay it. A total of close to $3000. Since then I have been getting the run around from them on who to talk to. I have documented the dates, times, names, and referral number of every phone call I have made since.
Representative 1 told me to have the doctor fax a letter of medical necessity from and then it would be covered. The Doctor faxed the letter which BCBS let sit in limbo until I called back and asked Representative 2 about the status of it. Representative 2 sent the letter to appeals nearly a month after its been faxed to them. Person 3 who was a supervisor told me that was not how appeals are done and that my options were to have the billing code resent as Diagnostic Surgical Benefits with Family History and if that fails I needed to send in a letter of appeal myself. Well the billing code resend happened but BCBS still didn't want to pay soI ended up sending an appeal letter back in June.
The letter consisted of every name, date, time, and referral number of every phone call I did and how they all told me wrong information. As well as my brother and his Pre-cancerous Polyp and the Letter from The Doctor stating that they have asked me to see them and that it was out of medical necessity. And Finally the outcome I wanted from the appeal which was to have them pay it 100%.
About a week ago I received the letter denying my appeal. Though they took care of most of the bill, they are claiming that it is not “Preventative Care” and that my policy states that “In-Network Diagnostic Medical Service will be subject to your in-network aggregate deductible in the amount of $2000” and that they will pay 80% and I have to pay the other 20% which is over $1000.00 at this point.
When I read the “Preventative Care” section of my Benefits Package it states “In-Network Preventative Care shall not be subject to any Deductible, Copayment or Coinsurance.” When I further read the “Preventative Care” section nothing states colonoscopy. It mentions: Gynecological, Mammograms, Prostate Cancer, Routine Adult Physicals and “Additional Preventative Services.”
“Additional Preventative Services. Shall not impose any cost-sharing requirements, such as Deductible, Copayment or Coinsurance on any covered Person receiving them:
“1. Evidence-based items or services that have in effect rating of “A” or “B” in the current recommendations of the United States Preventative Services Task Force.” USPSTF list Colorectal Cancer: Screening as Grade “A” for ages 50-75. Nothing about under 50.
“2. Immunizations that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the Covered Person.” In the Colorectal Cancer page of the CDC website under “Prevention Tips” it sates: “Learn your family history of cancer and tell your doctor if you think you may have a higher risk.” Which I am at higher risk. “If you’re younger than 50 years old but may have a higher risk of colorectal cancer, ask your doctor if you should start screening before age 50.” Which I am under the age of 50 and The Doctor asked me to be screened. This is a screening I’ll need this procedure done every 5 years and I do not want to pay or have to go through this again with Blue Cross Blue Shield.
The only foreseeable option Is a second appeal. I am waiting for my brother’s medical records to be released so that I may use that as leverage in my second appeal. I am unsure if I should grab more records of family history. Should Print out the pages from USPSTF and CDC mentioning that I should get screened and send them with the second appeal? Can i threaten legal action? Are there any departments I should contact for helps/rights? I’m at my wits end and any advice/tips would be greatly appreciated. Thank you!