Anyone with approval letters available?

[Diane]

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!

[sahuaro]

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?

[Diane]

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!

[Harrison]

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.

[LBP]

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

[LBP]

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!

[Terry]

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

[LBP]

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.

[Jmbeam]

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.

[katiejane]

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

[LBP]

when you say "mandate" do you actually have a copy of the FEHB policy letter?

You can find it online. Us Office of Personnel Management, Office of Insurance Programs, FEHB Program Carrier Letter (All Carriers) Letter No. 2001-27. It's not a case by case policy. That was the whole point of making the policy. Carriers were being inconsistent in applying their own standards vs FDA standards of what is "experimental and investigational."

look up the "mandate" read the policy letter!

Being a federal employee, you have a stronger argument than most. There is a guy a long time ago that won this argument when his private insurer denied him, against Fed policy. He got is surgery. do a "find" for FEHB you'll probably find him.

[ans]

I'd be more than grateful to see an approval letter from Anthem BC of CA and Empire BC/BS of NY. Puleeze!

ans

bicyclettes@yahoo.com

[Jmbeam]

Hello,

I would appreciate a copy of this letter also. If anyone else on the board has any approvals from BC BS I would be greatly appreciative. Thanks Jim

[Jmbeam]

Sorry you can send it to mygirls@twcny.rr.com
Thanks again

[ans]

I'm waiting!

The check w/be in the mail. http://adrsupport.org/groupee_common/emoticons/icon_smile.gif

[Terry]

Originally posted by Jmbeam:
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.

WOW. I did not see this post and missed putting in a reply. I had went to Stenum Hospital in Germany for my 4 level ADR surgery. I am at 20 months following my surgery and life is good. I am sorry for the late response.

Terry Newton

[Terry]

Originally posted by Terry:
<BLOCKQUOTE class="ip-ubbcode-quote"><div class="ip-ubbcode-quote-title">quote:</div><div class="ip-ubbcode-quote-content">Originally posted by Jmbeam:
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.

WOW. I did not see this post and missed putting in a reply. I had went to Stenum Hospital in Germany for my 4 level ADR surgery. I am at 20 months following my surgery and life is good. I am sorry for the late response. I would try to get BC/BS to pay for this first.

Terry Newton </div></BLOCKQUOTE>