Decision Time

[davidj8121]

Hey everyone,

Just got of the phone with TBI. BC/BS finally sent denial letter for 1 level ADR at L5/S1. I can have the surgery as early as 1/26/07.

Doing some sole searching right now but I keep coming to the conclusion that no matter what decision I make I may always second guess it depending on the outcome. Still fighting the Charite/ProDisc decision as well.

Decision Time.........!
There comes a time when you have done all the research you can do and you must finally make the decision. I am at that point.

Anyway, I do have one question about the denial. I guess is can only make sense to make an appeal. Has anyone out there paid for the surgery out of pocket, because of the time and pain factor, then proceeded with the appeal post-op with any success?

Also, TBI quoted me $37,000 plus extras for the surgery. Seems on the high side from what I've heard here? The extras bother me because the were very vague as to what they were. Pathology tests, spinal cord monitoring, etc. Is this normal?

I do have an appointment scheduled with Dr. Yue at Yale on 1/22. Not sure if I should bother going to see him or just get on with it at TBI. They are great doctors from what I have heard.

Thanks,

DJ

L5/S1 Charite or ProdDisc at TBI soon

[Harrison]

David,

I remember being there in early 2004, feeling better about some progress towards a decision. The whole darned, elongated process is agonizing!

From the insurance perspective, my case was rather unusual. I went through the “normal” appeals process as dictated by BCBS of Mass., but went into ADR in June of 04 with a “deal.” If the Charite were to be approved in 2004, they would reimburse me for all costs (less the $500 co-payment). So, on the morning of the surgery, I plunked down $20,000 towards the (unknown) cost of the surgery! Luckily, the Charite was approved in October, and I did get paid. I know that this arrangement was very unusual. If you can, get the payment matters resolved before surgery.

It’s great you received a quote, as most institutions don’t have the financial controls in place to provide this. And your $37k number seems to fit in with the norm nationwide. See http://adrsupport.org/eve/forums/a/t...1/m/1931019712 for more, but here’s an excerpt from one of the topics:

Artificial disc - $11,500 (Charite’)
Surgical & professional services - $15,000
Hospital services - $8,000
Total - $34,500

I’d be curious about all the “extras” you mention, and how much they add up for the total. It sounds like you are 90% there in terms of the bottom line.

[Harrison]

PS: In case you didn't already see the new Insurance Appeals program, see this link:

http://adrsupport.org/eve/forums/a/t...1/m/6571055222

[davidj8121]

Harrison,

Thanks for the info. Already contacted the appeal assistant, she's already on it. Thanks for the info.

Just spoke with the billing department at TBI and Amy me told me, as expected, that most of TBI patients are paying for the surgery while continuing their appeal after-the-fact. Said she has one patient that has been in the process for over two years. Does it take that long?

Also, the denial letter clearly states that should the surgery be approved for coverage after my surgery date that the coverage would "NOT" be retroactive. This fully supports your thoughts on ironing out the details before hand.

How in the heck did you get your insurance company to work out such a unique "side-deal" for the reimbursement of your costs?

Pretty clever.

Thanks again,

DJ

[LBP]

Daivid,

I would still see Dr. Yue, if nothing elese, he might help you in your decision of charite vs prodisc.

Before your appeals are exhausted, you might want to research and talk to a plaintiff's side attorney with experience in bad faith insurance claims. looking back I wish I would have talked to someone with bad faith ins experience. I think there is a possible angle here for a couple of reasons: (1) device is FDA approved and therefore should no longer be considered "experimental and investigational" by any person, company or agency and (2) the double standard problem... if you were a federal employee with the same insurer you would get coverage. Since the Office of Personnel Management for the Federal Govt has determined that ins companies cannot claim an FDA approved device is still investigation and experimental for it's federal employees, it forces private insurers to cover this procedure for it's federal employees...

So if BCBS has to cover the procedure for a certain sector of the population because of a federal determination based on a federally approved device, it seems to be in bad faith that ins companies claim the same device is still "investigation and experimental" to the rest of their insureds!

I've already exhausted my Cobra with my private insurer which could create problems for me to do this but I think someone else or many others could join even a class action lawsuit on this issue to help force insurance companies to start covering this procedure! Just need someone with the right contacts.

I know of one or two firms in San Francisco that could be approached and if your interested I could try and help you locate someone closer to your area. let me know.

[jf110]

David, I won my appeal with BCBS for one level L5S1 Charite ADR surgery. Dr. Blumenthal did the surgery at TBI in 2004. If i can help you with copies of my appeal process please let me know. Some very good information about procedure codes from the goverment for ADR. Hope I can help you, Mark

[fl man]

David,

If you can afford to pay for it then there won't be an appeal process if your insurance dosen't pay you back for an FDA approved procedure. Read your ins. contract or have a lawyer read it for you. If you comply with their rules and can avoid the pre-certification process then they have no valid reason for not repaying you. The main rule to find is how long of a planned hospital stay is needed to kick in the pre-cert. process. Mine was 3 or more days. Once the surgery is done and they owe you the money they will have to live up to the contract. In not you can sue them. They can say no all they want to keep you from getting it done but once it is done you have the power and proven damages if they won't pay up.

Good luck and feel free to ask more questions

Pat

[Sharon]

Dave,
My husband's insurance denied my ADR surgery at first and we put together a very convincing 3 page letter that worked for us. If you would like I can email you the letter and you can look it over and use it if you think it would help your case.
Sharon

[fiddle]

David,

For your comparison, I had a one-level ADR with the Activ-L disc done at the AlphaKlinik in Munich, Germany. Surgery was in July, 2006. It was at level L5-S1.

I was charged just under $30,000 USD which included the back brace, PT, massage, all doctors including a neurologist, prescriptions, as well as surgical and clinic costs. This price did not include the airfare, hotel, incidentals, and all expenses for a family member to accompany me.

I was denied insurance coverage. I am in the appeals process now. Good luck!

[luv2bfit]

hi,
i wanted to know if you ever got you ADR. I am a mom, 36 yrs old with 4 level of DDD. I am currently appealing Aenta's denial but it looks good. I am concerned b/c of the claims that the charite disc may be no good. Any help? thanks!