We Aussies have a quaint expression for folks that behave like that "mongrels". There are so many precedents as well as scholarly research and published papers that health funds must be running out of ways to weasel out of this. After all, it promotes better health, isn't that what they want??
I know the US system will likely be different, but outside of the US in "English Law" systems like UK & Aust they have a body that oversees health funds etc - there;s usually an ombudsman. When I had the hassles with BUPA is trawled the UK Financial Ombudsman's website (
Financial Ombudsman Service) On that site you can find the appeals logic required as well as what health funds must/must not do. It's basically there to make sure people get a fair go. One point they do make on that website is about "experimental" techniques. They list there an organisation in UK that classifes whether something is experimental. And i just found the doc (
http://www.nice.org.uk/nicemedia/liv...4935/44935.pdf).
Basically, disc replacement is classified the same as hip replacement!
Also- there are examples on the website (ombudsman) where claims are upheld against the health fund if they do not specifically exclude a procedure.
Hope this helps.