Letter of Medical Necessity

[brokenbrian]

Thanks for the link Ken. Im gonna have to get some more info from my insurance. So far the two people Ive talked to seem like they dont want to give me and info. I will just keep calling back, I get a different person every time eventually one of them will give me some answers

[annapurna]

Originally Posted by Jstuckey

You'd have to check with your insurance, but I would think that would be rare. My personal insurance says a precertification is for that surgeon and that procedure only. Any other doctor or procedure starts the process all over again. But there is no set standard. I think insurance companies can do what they want. I've seen posts by others that had their US insurance companies reimburse for oversees ADR surgery. THAT is good insurance, which I obviously don't have. Keep searching! Read the insurance warrior thread. It might give you ideas.

I bet I'm confusing things. I've heard of letters of medical necessity being different form the information used to precertify a procedure. I'm probably wrong in this case but I assumed that you were talking about getting a letter from a doc who has examined you and is stating that you need to have surgery then you'd get another pile of information to precertify you from the actual surgeon, who could be the person who did the first letter but doesn't have to be. You might want to check what the letter has to cover.

[brokenbrian]

The letter is just to get the insurance to prove it. So far I havent gotten a straight answer from them on whether or not the Dr that writes the letter has to be the Dr that will preform the surgery. But Im slowly learning more and more and atleast I am somewhate getting the ball rolling.

[Jstuckey]

If it helps any, in our therapy department, we are the ones that have to request the authorization to perform the services we wish to bill for (when an insurance company requires it). Only the medical professional performing the services is going to know the exact procedure codes to request. I think you're doing it backwards... find the doctor that you agree with first, and then that office will perform the necessary authorizations on your behalf.

[brokenbrian]

Originally Posted by Jstuckey

If it helps any, in our therapy department, we are the ones that have to request the authorization to perform the services we wish to bill for (when an insurance company requires it). Only the medical professional performing the services is going to know the exact procedure codes to request. I think you're doing it backwards... find the doctor that you agree with first, and then that office will perform the necessary authorizations on your behalf.

Thanks for the advice.

I did finally find one place here in MN that does ADR. I have set up an appointment for a few weeks from now. I will see what they have to say and go from there.

Do you have a date set yet for your surgery??

[Jstuckey]

Originally Posted by brokenbrian

Do you have a date set yet for your surgery??

No..... taking longer than I thought to hear back from insurance. Still waiting on the decision of my 4th appeal. I hope it's this week, if I'm still on the same track for April dates. Otherwise, I'll have to figure out new dates.

Believe me, I'll announce it to the world when I actually get an answer and get scheduled!
Good luck with your appointment, and pain control in the meantime....

[longroadahead]

Does your insurance pay for Fusion? Is so, one option would be to fuse the L5/S1 and pay out of pocket for ADR at L4/5. Since the majority of the cost would be paid by insurance for the fusion your out of pocket cost for the disc would be $21,500 (at TBI). There are several financing avenues if you needed to go that route.

This is a hybrid and seems to have good results.