August 25, 2003
Anthem (BCBS of NH)
3000 Goffs Falls Road
Manchester, NH 03111-0001
Attention: Michelle A. Belyea
Re: Administrative Denial of Service
Insured: Bernard J. Wolfe, Jr.
Member ID: 00836143701
Provider ID: 0655000
Type of Service: Out of Network Referral By Dr. Kevin Connolly
Appeal of Denial of Service/Insurance Payments
Dear Ms. Belyea:
I want to thank you for your prompt response to my request.
I have previously sent with my first letter of appeal copies of letters and documents as well as two CDs.
The CDs are duplicates in the event another department needs to review the case.
In order to evaluate the present appeal and the difficulty of getting information to Anthem for consideration of payment, it is necessary to review the medical history set out in the CD.
I am also enclosing a copy of the letter from US Representative Charles Bass pertaining to the contents of the CD. However he indicates he cannot act as an attorney on my behalf. As indicated the CD has and continues to be released. It has been on the internet at website, www.bjwolfejr.com for some time.
I am enclosing my first letter of appeal of July 27, 2003 with which I sent copies of many records. I have highlighted and underlined the items previously sent to your office. If you do not have them, please advise so I can fax and mail them to you for consideration. You will also note that I have slanted several sections. You have indicated that the appointment with Dr. Connolly for my annual physical was paid. My wife upon checking with Cottage Hospital Billing Department, was told that they inadvertently sent the claim to Healthsource instead of Anthem. I am enclosing again that bill as we received it. Hopefully they will send the material to you for your consideration. The appointment with Dr. Connolly on June 6, 2003 was for him to evaluate the infection in my jaw. I would not go to a doctor to evaluate a tooth.
I will bring together all the remaining threads of this present matter in this letter. I will only refer to letters as needed herein (and not include copies) which I have sent to you previously. You indicate you will go over your file and notify me of any you do not have and I will fax any omissions to you.
In our telephone conversation today, you indicated that it was not necessary to have the CTScan films in order to make the evaluation as the CTScan report from Cottage was sufficient. I am going to send the prints of several of the films for the file.
I am enclosing copies of the records I requested and received from Dr. Dodson. You should have received an exact duplicate as I paid for them. They have been numbered each on the bottom right for a total of 10. I am reciting them based on chronology so they are not in numerical order.
REVIEW OF DR. DODSON'S RECORDS AS RECEIVED BY BERNARD J. WOLFE
10. Dr. Dodson's progress notes of May 27, 2003
9. Dr. Dodson's Office Note. As to drainage into the nose I did have spells of drainage especially in the initial stages of antibiotics and soaking the area with warm water. Although I requested from him and the records department complete copies of all records including x-rays (not the CTscan) copies of the x-rays were not sent to you or me. I will again contact them for the fourth time.
8. My June 2, 2003 letter.
7. My fax of June 2, 2003.
6. My fax of June 4, 2003 to both Doctors requesting referral, procedure number for the insurance and cancellation.
5. My June 4, 2003 letter to Dodson and Dr. Connolly. I did not receive any response from Dr. Dodson and was informed by Dr. Connolly's office that he would make the necessary referral in network for the CTScan at Cottage Hospital and file the necessary paperwork with Anthem to get it covered by the insurance. In reliance on this, I underwent the CTScan at Cottage on June 9, 2003.
4. A second of my June 2, 2003 letter to Dr. Dodson. He made notations on the right margin. On my concerns about pulling a tooth while there was still an infection for which my doctor had prescribed antibiotics. He indicated "not necessarily and need to get a good sample for the ... biology" He did not send this information to me.
3. My fax of June 17, 2003.
2. My letter of June 17, 2003 upon which there is a note that 6/20/03 someone spoke to me primarily on scheduling the next appointment. I told the nurse that I was still trying to get insurance coverage verified and would get back. Someone made notations on the letter.
1. June 20, 2003 Response to Letter (my letters of 6/17 and 19/03). Although I requested a response or discussion with Dr. Dodson of my concerns, he did not send this or discuss any of it with me. As indicated in my prior letter, I called and only talked to a woman I assumed was a nurse who indicated the scan films and sinus were OK.
Other than the first appointment with Dr. Dodson, he has not discussed anything with me. Dr. Connolly in my last appointment indicated he had called Dr. Dodson and had a discussion concerning the procedures, etc.
I had a scheduled cleaning etc. with a new dentist scheduled and then rescheduled on June 23, 2003. She indicated that my gums were healthy and normal. When she wrote her Report of July 1, 2003, she included everything possible including past events but did not indicate any problem with my gums. This evaluation on June 23, 2003 was about a month from the evaluation by Dr. Dodson on May 27, 2003 after I had been on antibiotics for some time and the infection had finally been brought under control.
REVIEW OF DR. CONNOLLY'S RECORDS AS SENT TO ANTHEM
I have not received copies of records from Dr. Connolly.
You included a copy of Dr. Dodson's Response to Letter with Dr. Connolly records so I assume that Dr. Dodson sent a copy to Dr. Connolly.
His notes on our June 25, 2003 meeting for my annual physical.
I had several reasons for being hesitant to just go to the next appointment with Dr. Dodson.
1. Although I had repeatedly expressed my concern of getting the proper authorization from Anthem for insurance coverage, I could not get anyone involved to contact Anthem to submit what was needed by Anthem. I do not just undergo tests and procedures without a reason and without those making such recommendations setting forth sufficient medical reasons especially to my insurance company.
2. Although I had written several times requesting information about the CTScan results, the infection (see my letters), he did not respond. The only way I have found out anything subsequent to the first appointment was through verbal information from third parties, primarily from my primary care doctor who had to request it.
I am 62 years old and have become familiar with the healthcare system. Most people my age treat doctors like other professionals but with even more concern as it directly involves our lives/our well being. If a procedure or operation is recommended, I ask questions. I want to know the reasons for it and the possible unexpected as well as the expected results. I put my requests and questions in writing as I want to be sure they fully understand my questions. I like to get a response in writing but my getting a written response has been as scarce as there are hens' teeth.
Most who have gone to a dentist with an infection surrounding a tooth that may need to be extracted, given a root canal or even worked on in non-emergency situations are placed on antibiotics to reduce the infection to avoid possible complications from the infection spreading. I have a brother-in-law who was placed on antibiotics for an infected tooth before extraction for just that reason. I was placed on antibiotics several years ago to reduce infection prior to having root canal. The dentist did not want to disturb the area for fear of spreading the infection. Based on prior advice which appears to be the usual practice, when he told me to stop taking antibiotics for at least seven days prior to the tooth extraction, I became concerned about possible further complications.
Possibly the biopsy should have been done while I continued on the antibiotics or after the antibiotics had reduced the infection and the tooth extracted. If the gum was the result of a tumor, the absence of infection and the bad tooth, I would think, bring a clearer result, than having an infection, a bad tooth and possible tumor to sort out in the tests. Whether his recommendation to go off antibiotics was for the CTScan or the biopsy, he never addressed my concerns.
I want to know the risks as well as the benefits. I also ask for clearer answers and reasons to be sure I fully understand what is going to happen. I may go to other sources such as medical treatises as well as my and other peoples past experiences. I even have tried to get second opinion if I am not satisfied with the answers. Also in light of the medical events set out in the CD, I do not assume anything but ask questions.
Am I being a difficult patient by doing so? I am following the recommendations of many who have concerns about the problems in the healthcare industry. Doctors should have to respond to patients as well as insurance companies who pay the bills.
I agree with everyone that the loose tooth needs to be extracted but is it still necessary to have the biopsy of the gum? Does it now need to be biopsied? What about the recurrence of the infection and irritation?
I know that Dr. Connolly is not a dentist and cannot give expert advice but only make a referral if it is clearly and solely a tooth issue. Again I did not see him because of a tooth problem.
I do not know who has talked to whom, Drs Silloway, Dodson and Connolly. When I went to see Dr. Connolly and Ms. Brezina in his office, there was an infection in my jaw and gum with pain going up into and underneath my nose on the right side. You can review the To Whom it may concern letter from Dr. Connolly.
As to his material on our discussions with regard to the medical practice out to get me, there has been some detail left out as well as the addition of a good measure of hyperbole. He was given the CD as part of my records. We were discussing the events set out in the CD. He raised a concern that because of the events set out in the CD, I may now be hypersensitive and over reacting to everything. He indicated a concern that I may now be jumping to conclusions because of these past events.
I indicated that I did not have a long standing fear of doctors and dentists. Prior to 1995, I had excellent dental and medical treatment. I had successful extractions of my wisdom teeth, root canal, surgery on the right testicle, etc. I told him the CD is based on records prepared by professionals not me, that the CD only listed some of the incidents for fear it would be too long and no one would read it.
If you review the CD, you will find that how the records were obtained was carefully thought out and painstakingly prepared. As the records were prepared by the experts/doctors/dentists they are admissions. As they were placed in my file, I can release them to the public and have done so. I have made it a point to make sure that the parties involved are aware of its release including the CD. I have been releasing portions for over three years but those involved do not respond.
The usual course of action, if I was putting out false information, I would be covered with lawsuits. However at least for now one cannot be sued for releasing one's own records. Also at least for now one cannot be sued for the truth.
I want to be completely fair.
Dr. Connolly is an honest person trying to survive in an ever increasing dysfunctional health care system in crisis. When you review the material on the CD on Berube please note that in spite of the blatant damage, the closest I ever got of a bad word spoken by the other professionals (except my expert witness), occurred when the first doctor at Mass. Eye & Ear, Mark Rounds, looked at the damage, the size and location of the hole into my sinus. His jaw dropped with his mouth open in disbelief. He was literally speechless for an inordinate period of time, then he blurted out, he must have had some reason for it.
Dr. Connolly and his chief nurse were very concerned about the dangers of the continued infection and took an active part in trying to get me an oral surgeon. He was so concerned that at my request he gave me a letter to carry when I went on a trip out of the area. If I had complications and had to go to an emergency room, it would help to avoid what happened at Copley Hospital. He is largely responsible for getting the infection under control with the use of antibiotics although he was concerned with continued use when surgery could be the only long term solution. He even said that if all else failed and no one would take me, that he would recommend that I go to an emergency room at a large hospital, get admitted and refuse to leave until they properly treated the problem.
If you need any further information, please call me.
Bernard J. Wolfe, Jr.
c: Dr. Kevin Connolly Fax 1-802-222-9276