What if I wait to continue appeal?

[ERvet]

So, I've gotten the first two denials for disc arthroplasty (no real effort on my part, yet....just the standard form letters so far). I'm waiting to get some answers from my doc regarding other disc options (that are not yet approved), and wonder what happens if I:
a. Drop it now, while I wait to get answers, to probably bring it up again in the next 12-18 mos
b. Continue the appeals process, but wait to have any surgery until newer disc designs are approved (total optimist here, assuming I will eventually win the argument!)

Will the insurance company approve the surgery without knowing which disc will be used? All I can see is petitioning for disc arthroplasty, not which specific disc is being proposed (though it is currently the ProDisc.....not sure I want that one, though, which is the reason for the question...)

BTW, we are talking about Anthem/Blue Cross. Ain't it grand? So, while I am awaiting answers from this group, I am going to call my doc's office to pursue answers to the myriad questions I posed a couple weeks ago (in written form...) and have yet to get answered.

thanks, all!!

Susan/ERvet

[sahuaro]

You need to check your insurance company's rules for filing appeals because there is probably a time limit for each level of appeal.

[kimmers]

Susan,

In California, Blue Cross/Anthem/Wellpoint, is being sued by the district attorney of Los Angeles. See www.protectingtheinsured.com (http://www.protectingtheinsured.com).
They are being accused of criminal activities in denying coverage of procedures and illegal recisions, etc..

Good luck,

Kimmers

[LBP]

When I was in the denial/appeal process, I had PacifiCare. I was told that I could start a whole new appeal process for each new manufac of disc. I don't know if your ins has the same approach so you must call and ask. With that being said...you cannot just forget about an appeal for awhile and then pick it up when you want to. I agree with Saharo said, if you don't file appeals within the timeframes set by your Ins co. rules, you lose your right to appeal. It's all very strict.

In order for you to get to the appeal stage, your surgeon would have had to submit a pre auth for a specific surgery with a specific disc. It's not a general request for back surgery. So, on this level, your post is a little confusing. Ask your dr office which disc they submitted and ask your ins company for all of your records justifying their denial decision.

And, I don't think you get that many levels to appeal. Has your ins co informed you that you get a 3rd appeal level? Or are you at the stage where your only recourse to appeal to the State Dept of Ins (which is also usually futile) Please be aware that the State Dept of Ins may not let you file appeals for more than one surgery/one disc manufacturer...call before making any final decisions of what to do.

[LBP]

BTW..Kimmers,

You are always so full of interesting info! Hope you're doing as well as I am.

[ERvet]

kimmers, LBP, sahuaro:

Well, that answers my questions! thanks. So I guess I get to keep on fighting.....BUT, suppose I do drop it now, and when new discs are approved (as I assume they eventually will be...) can I have my surgeon submit a new request? I suppose these are questions for the insurance company, assuming they will give me a straight answer. Perhaps now is the time to see if my hospital's corporate parent has some sort of patient advocate, eh? Thanks for the info, I really have no idea how insurance companies work, which is exactly where they like us, eh?

Susan/ERvet

[epiphaknee]

Your insurance company is certainly not your friend in this process. They are more than happy leading you along to a path which will result in a denial - hopefully by tripping you up on some written procedure within their plan document, which you fail to comply with. Your hospital might deal with this insurer on a daily basis - do you really think they would be a strong advocate for you?

It seems like now would be a good time to consult with an insurance attorney. It would only take about one hour and would help you better frame the steps that you may want to consider within the appeals process. Notice the reputation that your insurer has and no doubt will continue enhancing until forced to alter their behavior. Their game is denial! It's all about the money. The brief that the state has filed against the insurance company most likely will have brief discussions of their egregious behavior against certain patients/beneficiaries and sometimes plaintiff's attorneys will be mentioned. This is an excellent source to mine for attorneys because they already know the "deal" and have experience with the insurance company. Typically these attorneys were the catalyst for the state to actually take action.

Even if you don't want the Pro Disc, it seems like it would be prudent to continue with the entire appeals process. You may change your mind regarding the Pro Disc, your back may get worse and necessitate more immediate surgery (which is now approved or near being approved), you will learn a lot from working through the process once and be better prepared for round two (the appeal for the artificial disc that you really want, that is now FDA approved), approval of a Pro Disc ADR may also provide you leverage, in negotiating for the disc, you really want to have implanted (e.g. trading horses with the insurer - Pro Disc is more money than Prestige, so "how about it?").

Anyway just my $.02!

[Terry]

Epiphaknee:

Good advice.

Terry Newton

[Jessica]

Susan -

No advice, sorry - just letting you know we are all rooting for you!

[ERvet]

Your hospital might deal with this insurer on a daily basis - do you really think they would be a strong advocate for you?


You may misunderstand me....my hospital is a veterinary hospital, as I am a veterinarian! So we don't deal with Blue Cross, we deal with Blue Ticks and Blue Heelers..... http://adrsupport.org/groupee_common/emoticons/icon_biggrin.gif
We are a corporate-owned hospital, however, and it is that corporation whose assistance I am seeking. We shall see what they say. I am currently in the process of talking with them. I'll let you know how that works out. I may also seek the assistance of the Pro Disc manufacturer's patient assistance hotline, or whatever they call it. I meet with my surgeon next week to get some more questions answered. Thank you for all the advice, it is precisely what I am seeking!!

Susan/ERvet

[ERvet]

Well, folks, at this juncture I have decided to stop the appeals process for the moment. I actually had one of the benefits managers for my hospital's corporate parent tell me: "insurance companies have your best interests at heart...." to which I (politely, but very much to the point) replied, I don't THINK so... Couldn't believe that statement. Anyway, I spoke to the folks at Prodisc, and then to my insurance company (whether they would give me a straight answer or not, it was a very simple question) about continuing to pursue the appeal, or to stop now and reapply at a time when I was perhaps closer to actually having surgery. I am lucky, as my back has settled down to a dull roar more recently, and I am not so annoyed with it. Other injuries are rearing their little heads up, demanding attention, and saying "ooooo, pick me, pick me!!" So I'm going to wait a while, and pursue this more seriously. I'm going to get Laurie Todd's book, and gather ammunition. Probably also going to get one more surgeon's opinion in the next several months. Folks at Prodisc actually seemed like they would be very helpful. When the time comes. So, in the meantime, I will continue to lurk, pop in with comments now and then, try to inject a little humor now and then, assuming nobody minds. Laughter is truly the best medicine. Along with a good NSAID.

Susan/ERvet

[Terry]

Susan:

You are a welcome addition to the forum. I love your humor and, laugh often at what I read from you. Aside from the pain you are in and the trials and tribulations of course. You have a wonderful attitude and, humor is definitely a plus. If we can support you in any way (other than rubbing out the person with the stupid response http://adrsupport.org/groupee_common/emoticons/icon_biggrin.gif), please let us know.

I loved the Blue Ticks Comment. http://adrsupport.org/groupee_common/emoticons/icon_biggrin.gif

Hang in there.

Terry Newton

[chasswen]

sue
as others have stated if you already started the appeals process then keep going as it will expire and then they win.
chuck

[ERvet]

Chuck: Unless I am completely confused, which I do not discount, I'm not certain I have started the "appeals" process.....I requested the surgery, they said no, doctor sent a "but" letter, and they said no. That is all the further it has progressed. I have no intention of dropping everything right now to have surgery, even if they did say yes (those other body parts are screaming much louder right now...). Even Prodisc told me it would be better if I waited until I was ready to actively pursue surgery. I have no intention of letting them win....at this point it is a strategic withdrawal! Gathering more ammunition, recharging my phaser banks, and perfecting my cloaking device. So, I'm still in the game. I come from a long line of stubborn people!!

Susan/ERvet

[chasswen]

sue
i think you only get 3 appeals and if i remember correct you said you have done 2?
and each appeal has a shorter time frame for replys
just food for thought.
chuck