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Insurance Hell All insurance-related matters are here: Medicare, worker's compensation, appeals, denials, insights, wins, losses. PRICING is here too. Note: This forum has posts from 2006 forward. Older ones are in the Big File. |
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#1
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I am an insurance agent (kinda like a "warrior-in-training") who is working to MAKE the insurance company pay for my client's ADR with the new Prestige device.
Is anyone willing to fax me their approval letters from their insurance companies to assist me with "Precedent Data"? (608) 356-9785 fax Thanks so much! |
#2
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I am dealing with the same issues (see my post re insurance and cervical ADR). Would you mind sharing information as to which insurance company you are dealing with and whether they have already sent a denial?
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2001 MVA; C5-C6 disk extruded ongoing physical therapy, exercise and massage ESI's, oral prednisone, trigger point injections foraminal and central stenosis C5/C6 and c6/C7 2007 EMG/nerve conduction shows pattern of chronic radiculopathy January, 2008: Prestige ST Artificial Disk Replacement, C5/6 |
#3
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My client is insured by Midwest Security, which is a medium-sized regional health insurance company owned by UHC, who seems to be notoriously unreasonable with this issue. Surgery is scheduled for Thursday, and our attempts to precertify benefits has resulted in a resounding NO from the review personnel as the therapy is "unproven". I am determined to get this covered for my client! I know that approval letters from other insurance companies (or even--dare I hope--UHC) would be of utmost help as I work through the appeal process.
Thanks for any help that anyone can offer! |
#4
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Diane, it may be tedious, but sift through this forum manually (see the page #s in the upper right?). There are many years of posts (The Big File has 2006 & earlier) and some patients have succeeded in reversing a decision. When you find someone via their post, email or PM them and ask them for their appeal.
And very few people will appeal to the state agencies (e.g. office of patient protection), where their appeal will be heard by a third party reviewed. Email or PM me, and I will send you a template that has been useful. Also, you need to be mindful of the bibliography that is used to reference/support efficacy. E.g., a good one is found on the charitedisc.com site.
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"Harrison" - info (at) adrsupport.org Fell on my ***winter 2003, Canceled fusion April 6 2004 Reborn June 25th, 2004, L5-S1 ADR Charite in Boston Founder & moderator of ADRSupport - 2004 Founder Arthroplasty Patient Foundation a 501(c)(3) - 2006 Creator & producer, Why Am I Still Sick? - 2012 Donate www.arthropatient.org/about/donate |
#5
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In my experience, it seems like the only people "approved" or won on appeal are people VERY early in the process before ins companies realized it was going to become so "popular"; or they were approved because the dr put though an ins code making it appear it was fusion rather than ADR (before current approved ADR codes); or they have a self insured insurance plan and have been extremely lucky to have an employer willing to override the third party administrator's automatic denial; they are a federal employee and they used the FEHB policy as grounds to override private ins companies policies; they've paid out of pocket and sued afterwards, or they have Aetna.
I'd love to hear about someone with BCBS, Humana, or UHC that's recent, and won on appeal that's not a self insured situation, pay out of pocket first, or federal employee situation! good luck
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Injured 9/01 Annular tears L4/5 & L5/S1 denied adr by insurance for 2 level charite as well as hybrid fusion at L5/S1 with Charite at L4/5. New ins paid for 2 level lumbar prodisc surgery on 4/7/08 (at age 39) with Dr. Westerlund, at Core Orthop |
#6
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it might be time to start writing all the presidential candidates. Health care has been an issued discussed at the democratic debates. The problem is that they are not really talking about our situation...where most of us have health care but are being denied an FDA approved medical device. I would love them to discuss making laws forcing private health care companies to cover FDA approved procedures...no longer should they be able to claim an FDA aproved drug or device is "investigational and experimental." Make them extend the federal policy to all private insurance plans.
We have that link re the Michael Moore documentary and the link of us sharing our denial stories. We need to make sure both parties and their eventual candidates understand our problem!
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Injured 9/01 Annular tears L4/5 & L5/S1 denied adr by insurance for 2 level charite as well as hybrid fusion at L5/S1 with Charite at L4/5. New ins paid for 2 level lumbar prodisc surgery on 4/7/08 (at age 39) with Dr. Westerlund, at Core Orthop |
#7
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LBP:
My 4-level ADR surgery was denied twice and then paid the full amount. I had a lawsuit going on over the homeowner whose dog attacked me and caused my injuries. Blue Cross had a lien and, to settle that, I agreed not to appeal their denial. I signed away my right to appeal and then they paid anyway. Go figure. I have been very happy with our Blue Cross of Michigan. I think they have been an excellent company and definitely stood by me. They are non-profit in our state. I believe they looked at my 4 level ADR surgery as being much cheaper than the multi-level fusions that I would have had to go through. Our company is not self-insured and we have a BC/BS plan for all of our full-time employees and their families. It might have helped that I am the executive director of the company but, if so, they probably would have approved it from the start. By the way, this was paid January 2007. Terry Newton
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1980 ruptured L4-L5 1988 ruptured SI-L5 1990 ruptured C5-C6 1994 ruptured C6-C7 1995 Hemi-Laminectomy C5-C6, C6-C7 Mayo Clinic Bicycle Accident 2004 MRI, EMG, Facet Injections, Epidural Blocks, Lumbar Discogram. Stenum Hospital Surgery November 4, 2006 Prestige Disc C5-C6, C6-C7 Maverick Disc S1-L5, L4-L5 |
#8
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Terry,
Lucky you! You do seem to have a unique situation with the personal injury lawsuit related to the need for surgery. You're lucky to get a 4 level ADR when it's only approved for 1 level.
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Injured 9/01 Annular tears L4/5 & L5/S1 denied adr by insurance for 2 level charite as well as hybrid fusion at L5/S1 with Charite at L4/5. New ins paid for 2 level lumbar prodisc surgery on 4/7/08 (at age 39) with Dr. Westerlund, at Core Orthop |
#9
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Terry,
Where in the US did you have a 4 level adr performed? I had my films reviewed in Germany and require a 3 level ADR. However I dont have the required $50K+ to get it done. My wife has BCBS and I am also on Medicare via Social Security Disability. Do you think it is advantageous for me being on Medicare or would I have a better shot in getting Insurance approval if I only had BCBS? Thanks for any input you can provide.
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Hybrid surgery performed by Dr Clavel Nov. 2012 Adr- S1-L5 with M6 Fusion- L5-L4 Adr- L4-L3 with M6 |
#10
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I have BCBS Federal...just heard about the mandate...but the company still reviews case by case. I would love to hear from anyone who has BCBS Federal and was approved for the Prestige.
Thank you so much! ladynubs@gmail.com |
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