Anyone approved by UHC?

[Paul]

I am starting to gather up my info for my first appeal. My HR departmnet says UHC wants to see "which carriers have covered this procedure and for whom" I thought I would start off by seeking out folks who have been approved by UHC. Please PM or email me if you have been successful with UHC.

Thanks,

Paul

[sahuaro]

Paul--
I too have United but have not yet gotten to the point of asking for approval. However, I think your HR department request is very strange and very out line, violating HIPAA privacy rules--are you supposed to supply them with patient names????

[APS]

I think as long as you have the patient's permission it's ok. I agree that it's a strange request but it's not exactly HIPAA since you're not asking another insurance company to divulge names but rather the person. I had the same thought at first though.

Andrea

[spotty14]

I know you want to provide them with the information they are asking for but shouldn't the HR Dept. be doing this research rather than the patient? They probably have easier access to the data. I'd also be concerned about HIPAA even if a patient here wants to provide the information to your HR Dept. Maybe they are wanting numbers of patients (no names), the carriers, and what levels were done?

[Kim]

Paul you can go to the website for Aetna and get their policy on ADR. They approve at least one level. I have asked others to give me their approval letter with all identifying info blacked out so I can use this with my appeal letter to show our insurance company that others are approving this procedure. It does not violate HIPPA if you yourself provide the info and there is no identifying information on the letter. Also HIPPA only applies to healthcare providers and insurance companies etc. It does not apply to the private citizen.
I think it stinks that we have to get all this stuff ourselves but if we want it done we have to do it.

[sahuaro]

I stand corrected. As a provider, I have a knee-jerk reaction to any infringement on patient privacy. Even so, the thought of providing actual names does not feel right. I would support Kim's suggestion of deleting any identifying info--this is what providers would do and this is all insurance companies have a right to receive.

[Paul]

It was UHC that was requesting it not HR. From me starting to dig into this I get the imnpression that UHC thinks the these artificial disks just fell out of the sky within the past year and they are all standing around it looking at it saying ohhhh what is that shiny thing? They seem totally clueless. Part of what I left out to the original post in addition to the which and who was; "was the coverage issue imapcted by the severity of the diagnosis or previous treatment tried without success" I don't even think they read the FDA approval which requires 6 months of conservative treatment, etc.


Kim, I plan on using the aetna policy as part of my appeal.

If anyone wants to keep their name out of it that's fine with me.

[sahuaro]

Paul:
I still think UHC is out of line in asking you to do all this research for them--but it was this kind of intrusive behavior that led me to resign from their panel as a provider.
Nevertheless, since I may be following you in requesting coverage, I appreciate that you are paving the path for me. Please let me know if I can help in any way.
Barbara

[APS]

Hi
Has anyone gotten anywhere positive with UHC yet and have anything to share?
I just got my denial letter. The language they used was "unproven" (as opposed to experimental or investigational I was expecting) and "not a covered benefit."
Sound familiar to other UHC people? Anyone else's employer on UHC self-insured plan? Does self-insured matter?
So here I go with my appeal...fingers and toes crossed.
Thanks.

I went the distance with United for a 2 level adr.
Ultimately, I was denied.I will be going to Munich in a few weeks on my own dollar. The funny thing is, I'm more positive about the outcome now. The doctor we're going to in Germany has more experience than anyone else in the world. Here, their experience is minimal.

[Harrison]

UHC is a bummer, as you may see from previous topics. (http://www.adrsupport.org/private-cgi-bin/ultimatebb.cgi?ubb=get_topic;f=3;t=000580#000002)I would not minimize the experience of US docs trained in ADR...many have 5 - 6 years and have learned from the best, as well as from the "good" and "bad" cases from Europe and elsewhere.

[Paul]

I see that my post came back to the fore. Yesterday was 3 weeks out for me on a 2 level 360 fusion. I'm still bitter about UHC. FYI, a 2 level fusion is a brutal surgery. Recovery for this is a slow process. Dr. Blumenthal did the fusion. Great doc but the rest of the experience, hospital, some nurses, pain management was the pits. Had one nurse who apparently didn't realize that a cather has another end besides the one that is attached to the bag or she had some issues with men. I thought she was going to pull my bladder out. Oh and she was the one that removed the thing too. I was bleeding after she was done with me. Left the hospital with a prescription for the same level of pain drug I had been taking for the previous year before the surgery. Needless to say that was no help.

[Juli]

I have UHC and they have denied coverage for the ADR though they did pay for the fusion at the one level and the majority of the other expenses, just the actual discs and fee they did not pay. I am going to be working up an appeal shortly myself. I am not counting on it, but my employer has the final say on the appeal so you never know. I wouldn't mind seeing my 20K back in my account!

Hi all, am new to this site, tho i am not new to UHC. They continually deny coverage for the Charite adr, tho my doc at TBI(Dr Guyer) seems to think that they may pay for one level, horay, i need two. Hopefully one day they will come to their senses. Are you all glad that you got the ADR procedure done??? Thanks yukon in Texas

[kristi]

Someone asked if "self-insured" matters? Yes, it does. Basically your employer holds a pool of money and has an insurance company like UHC to administer it. In the state of Texas, it means that the Department of Insurance has no authority over any complaints you might have. If your plan is self-insured, I would suggest that you get a copy of the Summary Plan Document from your employer. It is the agreement between employer and insurance company. Contact your employer for a copy. You may have to pay a fee for printing, but they cannot deny you access to it. It's not very interesting to read, but you may find some things that will help. A very nice man at DePuy suggested I do this. You may find you have some rights under ERISA. I am hoping it will be helpful to us.

Yukon, when did you see Dr. Guyer? When we talked to him in November, I think, he was not optimistic about UHC. Hopefully, you have seen him since then and things have changed.

I am Kristi's mom, and we haven't won the battle, but I would also encourage everyone to document, document, document. I mean keep a notebook or whatever works for you, and keep track of everything you do, and when you talk to someone from the insurance co. or dr. office, write down the date, the name of who you talked to, and what was said. If you don't catch the name, ask them for it. Your notes will really come in handy during your fight for insurance.

Good luck to all.

[Paul]

The way it was explained to me is that the company provides the pool of money and then it is put into a trust basically. The company can no longer touch it. So in my case I thought since it was the company's money they could tell UHC how to spend it. Not so. There may be other levels of self-insured but not in my case.

[Judy]

Paul my husbands company is also self insured and I was told that they do not over ride what the insurance company says and does. I thought the same that you could contact your company and let them make the decision.
I still had to fight and appeal my rejection just as if they were not self insured (I won by the way after 1 year of fighting) The best advice I can give anyone is document, and docment all your calls both before and after surgery. The main reason I won my case was the fact that this calls are monitored and writen in their computer systems as to who called, why and what the representative said. Fortunately for me the representative failed to tell me if the surgery was out of the country that they would not pay anything, also it was not in the benefit booklet supplied by the carrier. As a result they did change it. My advice is don't give up I truly believe that is what they want and think if they say no enough you will just go away.
Judy

Hi to the mother of Kristi, sorry it has taken me so long to get back to you. I just get bummed out with this back stuff. Anyway I did see Dr. Guyer in January of 06, mainly for another P Therapy prescript. I thought that since the fabulous insurance of UHC wont' cover this yet i will get more therapy and have them pay for something. Which it has helped just building up more muscle in the back. That sounds like a great idea document from the employer. Dr. Guyer said it just boils down to money, the insurance dosen't want to pay for anything that they don't have to. He says they may cover a single adr one day, but i need a double, so that again will present another problem with them. I am doing okay for now, I am not it alot of pain, just somtimes, I really would like to get this fixed for good tho. Hopefully one day they will cover it??? What do you think??? Thanks for the response. Yukon in Texas, how did you like Dr. Guyer???

I have UHC and went through 3 appeals already with a lawyer (denied each time) and am now filing a lawsuit. Ironically, I found out that someone with my exact same insuance plan through UHC was approved several months ago and UHC is claiming it was mistake. I had to pay for my ADR out of pocket but hope to get every penny back once I fight them in court. BEST of luck for ANYONE trying to get UHC to pay! I was told that they will pay in a couple years but I could not wait that long!

[go*big*red]

Well, I have Pacificare that was bought out or merged with or some such **&()(* with UHC. I am now working on my second appeal for the pre-auth with the help of my surgeon.

The whole thing has got me so fried - like we don't have enough to worry about with just plain living at this point!

I never can get a friggin straight answer with anyone I talk to at Pacificare. They send me to customer service who sends me to medical management who sends me back, etc. You get the pic.

The other thing that fries me is that the ADR is actually cheaper than the fusion. Let's figure for my surgeon it's an outpatient surgery - 23 hrs in facility and then home. For my fusion, I was in the hospital for 6 days. The hardware is a little more expensive for ADR vs fusion, but less complications.

OMG, when are they going to wake up? My surgeon is actually using this argument with them as I faxed over the hospital bills from my fusion which I'm sure is more now as it was a 3 years ago I think. Plus, the Charite' people are helping with figures and statistics on the surgery being pre-auth'd and ultimately covered in the past which has set a precidence.

I just pray that by the time the whole thing is done and I AM APPROVED, that it's not too late for the other discs. I can tell by the day that the others are becoming more problematic.

GRRRRRRRRRRR, how I hate my future being in the hands of some hot shot adjuster sitting behind the desk skiing on the weekends and doing whatever the heck he wants while I'm not sleeping or living even a half-way normal life.

Sorry - just a little rant.

[Dledezma]

Any luck with UHC???

[colorado2718]

I'm also insured by UHC and am disappointed by their published position. The last I heard, they published their official policy (2010T04371) on August 31, 2010 stating that "Artificial total disc replacement is unproven for the treatment of single or multiple level degenerative disc disease of the cervical spine in skeletally mature patients". They have an identical statement for Lumbar spine as well.