Community generated Insurance Appeal Letter

[DWebster]

Welcome everyone,

Here is my idea, for most of us the biggest problem has been getting the insurance companies to pay for ADR surgery. For many it has come down to appealing the insurance companies� decision. I would like to generate an appeal letter that has been worked on by the whole community. By doing this, we can gather more ideas, documentation and thoughts. The first thing we need to do is brain storm, having everyone submit their ideas and thoughts. Remembering no ideas are bad and none should be criticized!! This is very important or people will begin to be afraid to submit there ideas.

After we have decided what should be put in the appeal, documentation should be gathered to support the ideas. People can choose an area(s) that interest them or where they have already gathered good documentation. We should gather everything we can. My idea is not to make this a large document, but one with the effective points bulleted. So the more information we have, the better selection will be. As you enter your ideas and information assign it a number. This will make it easier for others to comment on. Just increment your number by one after the entry ahead of you. Again, remember this is just a brainstorming document. Please do not criticize anything!

After WE ALL have decided that we have all the information we need we can then try to assemble it. My idea is to not make this a huge document. I am a testing engineer and use different ways of submitting data. One of the ways is burry the information I don�t want to be noticed. An example of this would be, if you do not want something to be found, include it, but spread it out and cover it with fluff, I do not think this is what we want to do, and that is what can happen if a document gets to large. In my opinion, I think a document set up like a resume would be very effective. List all the facts up front and right to the point with references to the facts (incase they are questioned) in the later part of the document. We do not want them to just glance at it and then throw it aside. We are going to need someone or someone�s that have good writing skills to pull it all together. I can help draft it but I do not fell my writing skill are the best.

After we have the ruff draft together we need everyone to constructively comment on it. This should be done after each revision. If there is a disagreement on what should be put in and can not be resolved then I think Harrison should have the last voice in the matter but I don�t think this will be a problem. As a community we have a vast amount of expertise and knowledge to draw from. The last thing would be to have someone with legal knowledge to look it over. I real think this can be outstandingly effective and useful document.

I would like to thank everyone in advance for the work that you will put into this. For some the only reward will be that you have help our extended family, and for those that it help will extremely grateful

Dave

[Harrison]

thx for taking the initiative, Dave, and making this a priority!

Pls folks, any and all ideas are welcome. In the meantime, I'll summarize the two post recent study findings I posted here, (http://adrsupport.org/private-cgi-bin/ultimatebb.cgi?ubb=get_topic;f=1;t=000223)as they are significant -- and may have already played a role in these "secret" negotiations between the medical and insurance organizations!

[DWebster]

Yes Thanks Harrison these are very good documents that we should use, they will help prove the argument that ADR is superior to fusion the so called gold standard. These will be of great use. That has been one of the insurance companies agruments that there is not enough info to prove that it is better. the second part of there excuse has been they do not know the long term effect. we should be able to get this from overseas data. The have been performing ADR there for 15 years, I think that should be considered long term data. Lets keep it coming folks, this is going to be a great project.

[DWebster]

Lets get this started.

please list the reason people have been turned down.

1. I have heard that the insurance companies say they do not know the long term result form ADR: This has been done overseas for 15 years, thre has to be data someplace on how these people are doing.

2. information on the comparison between ADR adn fusion form the trials: this we should be able to get from the Information that harrison provided.

3. Cost of Fusion VS ADR, this should include operation, hospital stay, thearapy, meds, ect.

4. average for further surgery from effect of first (hope I said that right)

5. not they realy care but how have patients graded each surgery.

Please folks help out here.

[Cat-mt]

Webster, thanks for getting this started.
The reason given from my insurance company is as follows: That regulations and program policies restrict benefits to those devices, treatments, or procedures for which the safety and efficacy have been proven to be comparable or superior to conventional therapies. Any device, medical treatment, or procedure whose safety and efficacy has not been established is unproven and is excluded from coverage. I spent one hour on the phone with the insurance company on friday to get their defination of UNPROVEN, and no one could give me that information. I feel like i'm running in a circle and everyone has a stick and they are taking turns hitting me. I went to the hospitals medial libiary and pulled a bunch of info. One thing that needs to be in the letter is the cost of meds. I take Avinva 120 mg at a cost of $507.69 a month, we need to put in the average cost of meds. I have a friend that works at a pharmacy if I get a list of meds from everyone I could get the price for all of the different meds. I'm not working so if there is anything that needs to be done in the way of research or anything at all just let me know.

[DWebster]

Very good!! Can people please list the meds and quntity they take so we can try to come up with a average, even better yet would be anyone that has had fusion and rembers what they had taken. I am sorry to say this but can some put the denial into words we can all understand, this is realy not my field.

[Nichole]

SUGGESTION #2

Webster, I am taking 60mg of avinzia per day, 600 mg of neurontin per day, 110/50mg of Atenol/Chlor per day. I will have to let you know at a later time the cost per month of all my meds. Or if Cat-mt could check with her friend on those prices that would be very helpful. I dont have that info at the moment. I have had 6 ER visits in the last year for break thru pain treatment at approximately $875.00 per visit.

I am doing some research on fusions and the effectiveness of that surgery. I think adding information that is quoted from litertaure on the negatives from the fusion vs. the positives of the ADR would possibly be helpful.

more suggestions to come later, time for bed

[cavalier]

Hey there the basis of my denial has been EXPERIMENTAL & they do nto care about paying more money for a fusion or for med's. I have a sis in law who works for BCBS ( not in my state) & she too echoes as she is one of those who decides what they will or wont pay. They go for the gold standard fo what the FDA has approved but the procdeutre for a fusion or for ADR in preping the body is the same OTHER than the device so my arguement is pay ONLY for the surgery & NOT the device. Also BCBS has paid for others to have had this surgery BOTH P.D> & Charite so I am saying they can not pay for some & not others. Since my surgery was emminent & medically necessary they would have had to pay for a claim regardless. I am saying if they continue to deny this is my 3rd appeal I will have the expense of an atty ( which they can stall us for some time since they ahve atty's on staff) but when we go to court I will request a jury trial & also request extra money for the time & expense of an atty & the dealy in having them pay. I say pay all but the device of my surgery which was 21,5 K overseas at the International rate- I know it is silly as they would have paid up to 150k for a 2 level fusion - as the level above already herinated & torn would have had to have been included then in a fusion. They already have my MRI info - I am not normal in any of my lumbar discs but again it is NOT what makes good sense but it is whatever they can wriggle out of paying - however the fact is they would have paid more they do not care about. NOR do they care that this procedure gets one up & around sooner etc.
Hope this helps - Jill

[cavalier]

OOps I forgot to add I have a newspaper article I found by doing an search on the web - it states that BCBS is paying for CHarite ADR surgery in Fl & lists the doc & the hospital they are paying 50 K to 75 K for the same thing I had done except my device is diferent so they do pay for this procedure - I sent it in with my 2nd appeal & they have it on record - I am saying you are paying much more than what I am asking to be refunded to us. I am allowing them to exclude paying for my disc itself but obviously the surgery is the same so pay for it - I was still denied. I go for my 3rd appeal in person this Thurs. What you want is clear cases in writing published of where they have paid with the insurance companies named. Suggestion would be for more to search for such articles & compile them. I am short on time now as I have to prepare to leave I have to dfrive 6 1/2 hr's each way - so conveienent of them isn't it ? Plus much to do before I go -
Jill

[Harrison]

Folks, I think we need to give more thought to the "construct" or outline of this before we ask for things like price of medications (which we know are pricey!).

The main reasons why insurance companies are avoiding reimbursements are something like this:

1. Their policies dictate that "experimental" technologies are unproven; this is partly defined by the "legality" or approval of devices by the FDA. The other part of the experimental definition in their policies is driven by long-term efficacy data, which they report is:

- inconclusive,
- resultant from what they perceive as "flawed" or imperfect trial designs (from Europe),
- actually decidedly poor, in that early designs of devices (techniques and designs were truly experimental and certainly prone to high risks) resulted in complications and failures.

2. They are insurance companies, who strive to retain their market power and ability to make profits. Accordingly, their incentive for changing policies are not aligned to ours, by any means! Their policy changes need to go through layers and layers of bureacracy!

The rational for effectively arguing for long term efficacy and cost savings makes sense to folks here, but the approach (construct or outline) of this proposed document is everything. I know this comment is remarkably unconstructive, but perhaps our member friends in the legal world can give us some guidance. Bill, Leanne, others who have have first-hand experience?!

http://adrsupport.org/groupee_common/emoticons/icon_confused.gif

[Mariaa]

Altho my WC insurance carrier has authorized payment for ADR surgery (2 level trial) twice and I haven't had it done, I did receive a Non Certification when it went thru Utilization Review Appeals Procedure Worker's Compensation-California. Here is the reason:

Disc replacement is not consistant with ACOEM guideilnes. This is a clinical trial and no long term studies are available. Non certify.

[DWebster]

Harrison there is no such thing as a unconstructive response, right now we need all ideas and thoughts on this matter from everone. it would be easier if we we all in conferance room working on this but we don't have that luxury.

Cavalier,
Would your sister inlaw consider helping us off the record, an insider would give us a great advantage.

Keep them coming and then in a couple of day we will try to sort out what we need to use. Any Legal help would really be great!!

[Patrick]

As I mentioned to Nichole in her "appeal in person granted" thread, The Artificial Disk Study in the Professional Articles section has a bunch of great information and comparisons between fusion and ADR. It also stated some ADR posititive long term results from other countries.

[cavalier]

DWebster- ALL my sis-in law has added to this is the fact that what is more cost effective is not the issue. THey also do not care about the costs involved with apprvoed med's or the risks to the patient in their long term use.
If they can get by without paying by saying experimental or not enuf long term data they will. They are not there to pay for every claim that comes in willingly. http://adrsupport.org/groupee_common/emoticons/icon_smile.gif The fact that they would have paid 150K for a 2 level fusion also is just how they do things so cost savings is not ironically an angle.

The only hope is saying to ask for a exception based on medical necessity & the fact that this surgery is the same prep work required as in a fusion or Charite ( I had P.D.) & that to ask they pay for all but the device then since it is the same prep work & to keep hanging in there. If bothered enuf & it may require an atty. & the threat of a jury trial - maybe in time at best they may offer a partial settlement. We were not turned down until after my surgery & we had gotten back home - we had a case number & they sounded encouragaing this was not a problem, although they never said offically yes.

Jill L4L5 P.D. Dr. Bertagnoli Straubing Germany

[Paul]

Originally posted by Harrison:
which they report is:

[snip]

- inconclusive,
- resultant from what they perceive as "flawed" or imperfect trial designs (from Europe),
- actually decidedly poor, in that early designs of devices (techniques and designs were truly experimental and certainly prone to high risks) resulted in complications and failures.

[snip]

Seems like they are trying to have it both ways. They are saying they will only use US data on the efficacy of ADR and yet use old European data to prove their denial. With that logic I don't see why they don't deny brain surgery as the Inca's tried it and their patients usually died. Geez.

Also, I'm curious about the 2 reports that has Harrison has linked above. These seem to be presentations giving to professional meetings. Are these presentations then actually published in a journal somehwhere? I can see that being a sticking point as they can say this wasn't actaully published and not subject to a true peer review. Just my thoughts as I don't know the answer to this.

[DWebster]

Does anyone else have any ideas as to what we should put into the letter? I am soory I have nto been on more but it is getting realy hard to sit in front of the computer. I had a ESI today adn I hope in a few days I will be able to do more. well thisis the most I can stand for right now. if people would like to start researching for the ideas we have please do so.
Thanks every one.
DAve

[patty]

Hi all,
I am a newbie here but I am starting the process of figuring out how to appeal. I have been denied approval for the 2-level( L4-L5, L5-S1) ADR by phone.
I would like to join this effort.
I have a friend that is a statistician, runs a consulting center and has spent 2 years in Sweden working with a major university dealing with European data. I will ask him if there is a technique used for Analyzing European data that can account for "design flaws". It is worth a try.

Patty in Dayton, Ohio

[KevinSF]

I have my denial letter in front of me from Great West Health Insurance.

"We have denied your request because based on the clinical information received, the proposed procedure shows promise in this setting but is investigational and not yet approved by the FDA or supported by published peer-reviewed literature or scientific medical evidence. Investigational procedures are specifically excluded under the benefit plan..."

Although they clearly state that -no FDA approval - no ADR approval - they also seem to imply that if I had some "clinical peer data" that perhaps they would consider it????

[ans]

I think Patty is on target.

Maybe one reason for insurance trepidation is that the European retrospectives are both dissonant and one study reveals poor results - reportedly as a function of physician acumen (placing/sizing - I think acc'd to Mark).

But what kinda track record does fusion have? Not great.

I contradict myself; sorry.

[KevinSF]

Since I am in the middle of a fight with Great Worst Health Insurance - I received a new fax today from them. It was a 2+ page policy report on Interertebral Disc Prosthesis.

They include a lot of references to the succes of ADR but their policy states "...not covered since it is considered experimental"

and here is the info regarding the FDA approved Charite: "Despite it's approval by the FDA there is insufficient evidence available at this time to determine the efficacy of the procedure as a treatment for degenerative disc disease compared to standard treatment/ Controlled studies on artificial disc replacement in sufficiently large patient populations with longer-term follup are necessary to draw definitive conclusions about effectiveness, especially compared to competing procedures such as spinal fusion. Based on this assesment the procedure is STILL considered experimental and investigational and your appeal is DENIED."

Nice - the FDA trials were enough for our government but not for Great West...

I am at a dead end with them and I am in so much pain I can't wait any longer.

[DWebster]

Hang in there Kevin!! I know what you mean about the pain I am just one big ballof pain from the ribs down it is very hard, lets help each other get thru this. I am gload to see this is not dead, it seemed to have lost intrest for a while.

Patty, if you could get that info it would be outstanding, we need to hit this issue from every angle we can, it seems to be a big one with the insurance companies.

Ans, you also bring up a good point with fusion track record, it is the gold standard but I think it is fools gold, we should get data to compair.

Can people start signing up to research information. We should have at least two people for each item.

Thanks everyone
Dave W

[Nichole]

I would be happy to sign up to do research. What would you like me to research?

[patty]

ans,
I had a brief conversation with my statistician friend. There are ways to exclude particular datum from a particular study, but if the protocols are considered flawed by US standards, the study data can not be considered. Hate to seem like a downer a bit here, but I am a realist.
I have the transcript from the FDA meeting in June 2004 where the stats guys talked about the data.I want to look closer at this and maybe get my friend to look at it. He recently lost his dad and is trying to make up 2 weeks worth of work at the moment, so this will have to wait until next week. Hiring a stats consultant would help with this process. I will also ask how much it might cost to do so.
Also, I found an internet book on the appeals process. I downloaded it but did not have a chance to read it last night. I will look at it tonight.

Patty

[DWebster]

Nichole,
Do you have an interest in an area? I will try to go thru and make a list of the things we have come up with so far. I can't sit to long at the computer any more my pain is just getting to bad.

Harrison,
Were should we bring this information togeather? do you ahve a place to accumalate this much stuff on here? or should everyone just e mail it to whom ever is going to assemble it?

Dave

[Harrison]

Dave, you can start a new thread, or we can collaborate on the project by using the private forum -- ADR Incubator. The "secret" password is peace, for all those helpful folks that want to help "bake" this to fruition... (Hmmm, baked fruit? I must be hungry.)

[Nichole]

DWebster, let me know the area's and I will let you know where my special interest is....hehehehe I am actually interested in all areas but am sure I can pick a few that are my fav's.

Patty, I have the entire manuscript if you dont have it. I have it as a legal document and can email it to you if you would like.

I met with a rep from DePuy who will be attending my appeal with me yesterday and we chatted about some ways to approach this. He is going to sit down on Friday and go thru all that I have sent my insurance already and the rest of the information that he has and compile something then. I am really excited about his help. He sounds very educated regarding the disc(better be since he is a sales rep for the Charite') and sounds like he can possibly make a difference. We are also going to use the fact that Aetna is now considering this non-experimental. Generally once one insurance approves the rest will follow shortly. I just hope it's sooner than later.

Anyway, let me know the different areas and I will choose a few then.

I hope that more people volunteer to do some research as this will help us all.

[Cat-mt]

Could we get a list of the different insurance company's that are now approving ADR. Anyone that has gotten a yes from their ins. co. or anyone that has read about an ins. co. that is now paying could post somewhere. Just a thought. Thank goodness for my laptop, I have been in bed for 2 days, just because I turned the wrong way.

[ans]

Cat-mt: good question. (Sorry that as a veteran you have to struggle like this).

Sorry, no idea how Tricare operates (no pun intended).

Empire Health Choice, formerly Empire BC/BS of NY ok'd a two-level disc replacement (in small print they say that they can deny the treatment though). Not clear if BC of CA w/pay secondarily and utilization review nor doc's financial people can give honest answer. Atena's coming around too, as I'm sure others:

http://adrsupport.org/private-cgi-bin/ultimatebb.cgi?ub...t_topic;f=3;t=000187 (http://adrsupport.org/private-cgi-bin/ultimatebb.cgi?ubb=get_topic;f=3;t=000187)

Best of luck, ans

[Smiley]

I'm interested in helping out with research also. I have been reading some research studies on ADR (specifically the Charite). I haven't been able to get much on European research studies, but have a little. I would like to try to help in some way with this project, but I don't really know what would be helpful to do. I have a couple questions:

What format do would be best to report the results in?

What subjects specifically do we want to research or address? Some areas I would think might be important include:
- Effectiveness of adr (including ability to work, functioning, pain, satisfaction...)
- Comparison of results with fusion
- Results over time (especially long-term)
- Complications of adr
- Improvements and advances of adr surgical technique over time since its inception

What do y'all think?? I would like to know how I might be able to help.
http://adrsupport.org/groupee_common/emoticons/icon_smile.gif

[Melissa]

I have HighMark BS PPO and am trying to get approval for a 2 level charite. Dr. McAfee's office has told me that they have recieved approval once before from that insurance for a 2 level procedure. I also had another Dr.'s office tell me that they had approval from my type of insurance, but it was a the plan for Fedral employee's that would only approve ADR, but that was when I tried to get approval for the Prodisc, I don't know if that make a difference, but Carol from McAfee's office thought that would give us good grounds for if/when it comes time for the appeal if it was denied based on discrimation or something, I'm not sure.

[APS]

Hi, I'm new here but I'm in the same boat as everyone else who has been denied ADR by their insurance for "experimental" reasons.
I've been researching fusion v. ADR to provide info in my request for independent external review (my first appeal was already denied).
Is anyone familiar with this publication: Spine Surgery: Products, Technologies, Markets & Opportunities, Worldwide. I located it at http://www.mediligence.com/rpt-m501.htm
I thought it might be worthwhile to check it out re anything helpful to argue to insurance companies.
I tried researching some medical libraries but didn't come up with any leads and unfortunately I'm 3 hours from a major city with a university medical library.
I'm so lucky to have found this forum - thanks to you all - I'm here to share and join in the cause.
Just call me,
Refuse to be fused!

[bmills]

Seveal months ago, a local denver news station did a very positive story on ADR. That was before the Charite FDA approval.

So, as I am getting tired of all the insurance denial crapp, today I sent information to the news station as well as the Tom Martino Troubleshooeter (consumer reporter).

I've asked them to please follow up with another story to cover the FDA approval and also how people are suffering by the big insurance carriers continuing to deny the FDA approved procedure.

I gave them a little background info and referenced this web site as a great place for information on how positive the true results are for ADR.

Hopefully this will get some more news coverage on the subject.

If you want to see what I sent them let me know.

Brady

[ESL]

I think it would help if this letter you all are working on was actually two letters: one for fully insured plans and one for self-retention/self-insured plans......different motivations and criteria.

[bmills]

Is anyone out there also dealing with CIGNA HMO Healthcare?

Brady

[ouch1966]

Originally posted by bmills:
Is anyone out there also dealing with CIGNA HMO Healthcare?

Brady I have CignaHMO in TX. I was denied a two level charite earlier this week. I have my company's insurance broker working with his "single point of contact" at Cigna to see what he can do, but I am not too optomistic. I am fortunate enough to be able to pay cash so I am working on scheduling surgey with TBI in Plano.

If Cigna comes back and approves it before I have my surgery I will switch back to the less experienced CignaHMO ortho. If not, I will check with a lawyer and see if I have grounds for an ERISA claim and try to get reimbursed.

[cavalier]

Maybe a petition of numbers of folks might make a difference to insurance cant hurt - I wonder if someone could start this petition I am REALLY short on time - Too many things in the fire right now - but would love for someone to take this link - & do this - I came across this link for someone else's cause & I had this idea -
for ADR & INSUR. to put pressure on them - get big names to sign & a ton of people numbers can move mountains -=

All the best to all - Jill ADR 7/6 /06 Dr. Bertangoli L4L5

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[Nichole]

Cavalier, I would be happy to start this. I am not sure what to put on the petition though. If someone tells me what to put on the petition I will start one and start passing it around.

[andromeda1111]

F#@*ing

Dumb****s

At Large!!

They will deny anything that works as long as they do not have anything to gain by it in the first place, if they are not the ones implementing it TO BEGIN WITH, then forget it, is their philosophy, therefore...nothing can be done, getting rid of the FDA altogether is what needs to be done, only in my dreams...

They act as if they are the Gods of all law...They had come to the food plant at where I worked, and I gave them a hard time, I would not grant them access, (I am security there) they said they never in 15 yrs had anyone deny them entrance. I smirked at them, made them wait at the gate until I felt like letting them in. I enjoyed that!!
Laura

[biffnoble]

Blue Cross and Blue Shield of Florida.

Subject: Artificial Intervertebral Discs


http://www.bcbsfl.com/MCG/index.cfm?fuseaction=main.main&doc=10264#P27_1902