Did your insurance pay? Let's help one another

[walker]

I am beginning my first appeal with BC/BS of Oklahoma. Just wondering if anyone close to me had any luck with BC/BS yet. It would help those of us in the appeals process to know of others that were successful in their approval process.

I'll start it off:

Oklahoma
BlueCross/BlueShield
denied-"experimental" 3-7-2005
currently in 1st level appeals process

Thanks for any info you guys have.

[Cindee]

Mine paid 60% of everything. Blue Cross, California.

[walker]

Thanks Cindee. Congrats!

[walker]

Anyone else wish to contribute?

[ans]

BC/BS of NY (now Empire Health Choice) authorized a two-level ADR w/Regan in LA. In their small print they say that they can deny this too. Haven't had the surgery 'tho so can't say how things worked out.

[cavalib]

Does anyone know if CIGNA Open Access Plus pays for Charite?

[bmills]

I know of a person here in Colorado that had CG Open Access Plus and they paid. Connecticut General is affiliated with CIGNA.

I have CIGNA HMO and they have denied so far.

Brady

[cavalib]

Thanks Brady, you gave me some hope of them approving. I am starting to get depressed. I should "hopefully" know something on Friday. But these dr. offices are taking their time. Good Luck to you all.

[cavalib]

Can anyone tell me why in different states the insurance companies are approving and not approving of the surgery? I have cigna open access plus and I read a lady in L.A. has the same thing but was denied and then someone told me someone in Colorado has it too and was approved. What's the difference?

[DWebster]

Cavalib,
Each insurance is differant between state to state and eventhe same inusrance company in the state will differ between differant employers. it really makes things hard on us. I don't think it is fair or correct but my wife works in a hospital dowin this kind of stuff and she says this is how it is.
I just found out mine is approved but I feel guilty and bad that others are ahving to go thru this. It just doews not make sense to deny anyone this.
I wish you and everyone else the best in trying to work this out. Don't give up!!

Dave

[ESL]

i have posted this several times on many parts of this board, but no one seems to really notice....however it is a very important nuance wiht regard to the willingness of insurance companies to approve procedures......and that is that another factor is whether insurance thru your employers is a fully insured plan (in which case the decision to cover or not cover adr is up to the insurance companies) or a self-retention/self-insured plan (in which case the insurance company administers the employers insurance plan and appeals are up to the employer....usually a manager/management team/or cross hierarchal committee).

I am not trying to grind an axe, but just want to help raise everyone's awareness.

[NCFUSED]

ESL is totally correct, after 2 appeals with UHC,
which really were a waste of time because my company is self insured, the final denial letter from UHC told me to seek another appeal from my employer's benefit's committee, that they were the only ones that could overrule the medical policy that was in place.

One other thing I found out is with Self-insured plans, you cannot appeal to the state's insurance board. You would have to file a grievence with the Dept. of Labor, basically "marking" yourself at your job....

[cavalib]

DWebster,
Which insurance do you have? DId you have to go through any appeals?

[cavalib]

Does anyone know if Cigna Open Access Plus approved anybody from Florida? Does it make it harder to get approved if you are having the surgery in a different state? Sorry for all the questions but I am new at this and I didn't think I would be having all these problems when I first looked into the surgery. If anyone has any information that will help me please let me know. Thank you so much!

[ans]

Wonder what the secret formula BC of CA uses in saying yea/nea in acceptance - both in group or individual plans. For that matter, any ins. company.

[walker]

"Secret Formula"--what a way to put it! I guess that is what I am looking for. If I only knew how to cut out the nonsense/time-wasting appeal methods and cut straight to the chase and get a positive result. We need an insider - - - Someone who knows those magic words!!!! Hmmmmm.

[inflexable]

I was scheduled for adr @ l5-s1 on 4/8 but was just denied 3/29 "investigational/experimental" was the reason (excuse) given. The insurance co is highmark bc/bs of western PA. They are a 3rd party administrator for the company I work for that is self insured. My employer told me they can't tell bc/bs what to do...I wonder?? anyway I am appealing. I live in MD but my employer is based in pa with branches in maryland. My doctor was told by bc/bs during the peer to peer review "we are not paying for ANY disc replacments". I feel like they already have their minds made up to deny any appeals and that this is just a formality for them. Anyone else have the same insurer?

[ans]

We must do recon on different utilization boards! http://adrsupport.org/groupee_common/emoticons/icon_smile.gif

Wine/dine/romance/even marry Utilization Review folks and let's hear the secrets.

[letteski]

I am insured with Health Comp through Universal Health Network out of Northern Nevada. I spoke with my case manager yesterday at UHN and she said I was the first case she asked for authorization on for ADR. I was approved on March 14'05. Regan's office said I was the first to come in with pre authorization. Heath Comp pays the bills and I must remember, "Nothing is a guarantee of payment".

[ESL]

Paulette are you part of a self-insured plan thru your employer? My employer is self-insured with healthcomp as the third party administrator....their case management people are top notch.

[ans]

I have BC/BS of NY that authorized a two-level; also. a secondary BC of CA plan thru a university. Regan's office told me frankly despite this, I could get stuck with the bill - no guarantees. A bit unsettling. BC of CA's uitilzation review refused to answer directly if they have ever paid for an ADR before, re: precedent.

[biffnoble]

ADR procedures

There is also the issue of post-op care/follow-up.

INSURANCE QUESTIONS:
1) Who's on the hook for patient post-op ADR care?
2) How are USA versus non-USA procedures covered?
3) Non-USA & non-FDA approved?

If an FDA approved, insurance covered surgery is performed in the USA, then one would think that post-op care would be covered.

However:
If insurance covered surgery is performed out of the USA, and the procedure is non-FDA approved, e.g. multiple level cervical ADR, could the grounds that ADR is experimental, etc., be used as grounds for refusal of post-op coverage?

Or:
Self pay surgery is performed out of the USA, the procedure is non-FDA approved, e.g. multiple level cervical ADR. Could the grounds that ADR is experimental, etc., be used as grounds for refusal of post-op coverage?

Refusal of coverge would put the ADR patient on the line for 100% of, tens or even hundreds of thousands of dollars, of out of pocket costs.
A financial disaster for 99.9999% of patients!

Does this make �safe� surgeries (laminectomy, anterior fusion, etc.) any more palatable?

[ans]

Good points; rather sobering.

[Nancy from NC]

A couple more questions about insurance. I'm new here and still working on approval for a 2 level cervical ADR on top of a previous 2 level fusion. I already had a laminectomy on the area needing to readressed, and now have too much instability/lean, and then the previous fusion take me out of the criteria for ADR surgery in the US. So I am hoping someone in Germany will help me. Of course money is always an issue. So......
1. At what point do you try to get approval for a procedure overseas?
2. From what I am reading, am I correct in the fact that you can appeal your case before you have the surgery?
And My Main Question.......
3. Has anyone had any experience with complications after their procedure overseas and did their insurance cover the additional medical help/treatments that were directly related to those complications?

I appreciate any answers you might be able to provide. - Nancy

[casifer]

Hopefully some positive news for those waiting for insurance approval...

My ortho's office (Hamada, Los Angeles) just submitted the request to my insurance co (PHCS) 3 weeks ago to cover the Charlite ADR procedure at L5-S1. As an aside, this office also mentioned that not one of their requests for ADR coverage has been approved in the 5 months they've been submitting them.

30 minutes ago, I received the following vm from the office: "surprise, surprise, your insurance company approved payment for the procedure...".

No time-consuming appeal / denial / 2nd appeal, etc. process necessary. I feel very fortunate, after reading what most of the community has had to go through in getting insurance companies to pre-approve payment.

Hopefully as more and more of the insurance co's continue to approve the procedure, the rest will feel pressure to follow.

Good luck everyone.

[biffnoble]

Maybe the facts could be extracted from these posts and put in the FAQ's?

Each one of us is confronted with our own lousy scenario.

No ins.
Medi-cal
Medi-care
HMO
POS
PPO

Etc., etc..

There many other permutations to be considered.

Maybe when Mark gets the new 501(c)3 going this will be covered.

[Kim]

Congratulations on your approval!!!!! I am hoping to hear back from our HR dept with good news concerning my appeal on my surgery. I talked to the HR lady and she told me she should have an answer for me by the end of the week. Say a prayer its good news. Otherwise I start the ever dreaded appeals process. Our ins is self funded by the company my hubby works for so the company has more say so in the process. We are hoping they will take our side on this and tell the ins company to approve the surgery.
Kim

[Juli]

How do you know if your company is fully insured or self insured? Just call our HR I guess?

I called my insurance, UHC, to see what they had to say about coverage and the woman said she had nothing in her database regarding ADR and nothing against the CPT of 0091T which is what my research has shown to be the code for this surgery? She suggested I have my doctor submit a pre-authorization form and it will take about 30 days for them to respond. And I have yet to get a doctor to recommend it, so far they say fusion would be my next option, but as I can function day to day, they have not even recommended that although I have another appointment next month and I think that is what he is going to say as he said if the last round of PT and injections did not work that might be the "only" alternative as I have more than one bad level.

Anyway, it looks like it is the exception vice the rule for insurance to cover it at this point. I am probably going to have to come up with the money out of pocket and do the european thing, but am still researching and will be at the shindig May 1st.

Note NYC Jason's update about the moratorium in his new thread. Seems like it is roadblock after roadblock.


Juli
DDD L3-L4 on down since 1990

[ESL]

I have 3 codes on my pre-authorization:

63090 63091 and 22851

and you are right Juli.....your HR manager or benefits manager should be able to tell you whether your company (your hubby's company) is fully insured or self-insured (and if self-insured to what dollar limit).

[Juli]

Thanks ESL, does it give a description next to each code?

Juli
DDD L3-L4 on down since 1990

[NCFUSED]

Juli,

I also have UHC and was denied both for a pre-certification and 2nd appeal, with UHC saying ADR surgery is an "unproven service".

My company is self funded / insured, so my final appeal has been in the hands of HR Benefits Committee since end of March.

From what I found out is that if your company is self funded insured, the appeals process is a waste with the insurance company (took 5 months to get 2 denials from them), because with a fully insured policy, only the company's HR/Benefits Dept. can dictate a change in policy allowing the surgery....

[Juli]

Curiouser and curiouser. Well, I just called my HR and they confirmed we are self-insured. She said to submit the request to UHC and if they deny it to then contact HR for the appeal. She was not familiar with this particular situation but said the only way to find out was to ask, of course. Now I just have to get a doctor to stop waiting for me to become fully disabled before they recommend it! I have an appointment on May 10th so should be armed with some good info after our NYC event. I am going to also send my diagnosis and MRIs to the Alpha Klinik and see if they will respond before my appointment so I will know if I am even a candidate, though I believe I am.

Thanks for the info, I am learning so much here. What a resource!

Juli
DDD L3-L4 on down since 1990

[bmills]

Had my second level appeal yesterday. It was a 10 minute conference call with three (doctors) on the appeals committee from the insurance company. My attorney represented me in the meeting.

Our main point is that the insurance policy states that procedures are covered if there is adequate peer review information for the specific procedure showing its efficacy. Or at least to that affect.

The appeals committee had no questions for us. They just listened. We stated how there is much peer review information supporting ADR. We followed up with questions asking them to define 'adequate' peer review data, how much data is required, what data, etc? If they will answer those questions specificially, it should be feasible to be able provide enough data to meet the definitions since there is a large amount of data out there now supporting the benefits of ADR.

One thing I've learned with my attorney is; the important thing to know is - what exactly does your policy state? With adequate peer review information and with a doctor's recommendation for a specific service, they should be covering my ADR.

I really don't think the insurance companies can go much longer denying the procedures based on the fact they are 'unproven, experimental, and investigational'. There is just too much data available that goes against that claim, in addition to the fact that is has FDA approval. Maybe I'm crazy...

They will provide their answer within 5 days.

Thoughts...?

Brady

[ESL]

I think what NC-ADR meant to say was if your company is "self-retained or self-insured" not "fully insured" only the company can dictate changes or exceptions to coverage........

My pre-auth does not have descriptions next to the numbers....sorry.

[Juli]

OK, thanks though, very good info.

Brady, who is your insurance company? I must believe you are correct with your final statement:

I really don't think the insurance companies can go much longer denying the procedures based on the fact they are 'unproven, experimental, and investigational'. There is just too much data available that goes against that claim, in addition to the fact that is has FDA approval. Maybe I'm crazy...

You may be crazy anyway http://adrsupport.org/groupee_common/emoticons/icon_smile.gif but I do believe the insurance companies must be on the verge of capitulating.

[bmills]

CIGNA HMO.

No logic with health insurance companies on this issue...

[ans]

Juli,

But there isn't good long-term data on ADR's. At least we know with fusion, that many eventually w/lead to "failed-back syndrome". http://adrsupport.org/groupee_common/emoticons/icon_smile.gif

[biffnoble]

Hi Bmills:

What's the reference: [CIGNA HMO.] indicate?

Thanks.

[bmills]

Biffnoble, Juli asked for the name of my insurance company previously in the thread.

Brady

[biffnoble]

Bmills:

So your coverage is HMO. Very interesting. Are there ADR providers in your Group/State?

If you need to go out of Group/State what would you use as a basis for requesting HMO coverage?

My take on HMO's is that they'll: fight to keep subscribers in Group and in State and if your surgery is required and not elective they'll force you to accept what they deem to be an appropriate "accepted standard of care".

Do you have a report from an ADR (other expert) stating that the NECESSARY/REQUIRED (non-elective) treatment for your condition is ADR?

Maybe the concept that non-ADR could be considered sub-standard care and damaging to the patient could be considered a basis for suit against HMO's who refuse to pay for ADR.

However in the HMO situation I wonder if the subscriber is stuck with non-ADR that is considered an acceptable standard of care.

This gets really complicated for cases that require out of country care. Multi-level cervical ADR for example.

I wonder when the first law suits against insurers grounded on the argument that denial of ADR forces the insured to accept sub-standard care (trad spine surgery) with resultant long term ongoing damage to the patient, e.g. adjacent level degeneration caused by fusion, will be filed?

[bmills]

Yes there are ADR providers in my group and state.

I'm waiting for the answer from the second level appeal. I think my attorney's point should have been clear to the appeals committee. My policy really requires it to be covered due to adequate peer review data on the subject.

Brady

[biffnoble]

One wonders, for those of us that won't have FDA clearance for some years to come, how far the above arguments would go to support getting ADR overseas.

My sense is not very far with an HMO.

[Juli]

Biff, is that because you are a cervie? What is it that the FDA hasn't approved yet for you?

[biffnoble]

Hi Juli:

In the USA FDA approval (+ off label use) allows multi-level lumbar ADR implantation.

Cervical ADR lags behind (many metrics) lumbar ADR. The only FDA approved use is single level with no adjacent disease. Anyone that dosn't meet this criteria is SOL. I'm SOL. The only way that multi-level cervical ADR can be procured is overseas primarily, in Germany. See for example the story of Christy B..

Overseas cervical ADR may or may not be ins. covered, ditto post-op and long term care.

So although the world of the lumbie seeking ADR in the USA isn't peaches and cream it's way ahead of the cervie world. Hope this answers your question.

Good luck.

[Juli]

Wow, I didn't know they had distinguished between the two. Sorry to hear that as I know how difficult it is already. Thanks for the answer though, very informative as always.

[walker]

Wow, you guys. There is SO much information being shared here. I am especially happy to learn about the "ammo" you guys (bmills) are using in your fight for what's right! I have compiled an amazing about of info from this site and from the discussion boards for my fight. Keep it up---PLEASE!!!

[biffnoble]

Hi All:

Re: Multi-level Cervical ADR.

New info (for me): Multi-level Cervical ADR is possible in cases where the surgeon has determined the need for "compassionate care exemption". My understanding is that a 3-level Cervical ADR has been performed in the US based on a "compassionate care exemption". Mark of course would be the final authority on this. Maybe we could get a multi-level US ADR Cervie to post here.

[mmglobal]

I'm not a final authority on anything... but I do know of a 3-level ProDisc-C done in the US.

Mark

[biffnoble]

A quote (not from Biffnoble):

"Actually, the surgeons can use the discs as they see fit, it's mostly basically for insurance purposes that the FDA approval comes into play. It's not that the surgery can't be done, it's a matter of who is willing to pay for it. I am having to go before the worker's comp board to convince them that a 2 level surgery is necessary for me, so they will pay for it."

If true this statement has a lot of interesting ramifications.

[cavalib]

For those of you who I have talked to, I just wanted to let you know my insurance denied my claim for the ADR surgery. I just foind out on Friday and was a little upset but at the same time I was expecting it. I was asked if I wanted to appeal, but I decided I didn't want to. After reading all the stories and what people have gone through with the appeals, I figured it wasn't worth the headache. I guess my only option now is a fusion. Do they do fusions where they don't have to take bone from the hip?

[biffnoble]

Hi Cavalib:

One alternative to hip bone is cadaver bone which is procured from a bone bank.

[Kim]

Wellllllll I heard from HR today and they said that the panel agreed with Great West to deny my coverage for ADR. She said of course I can appeal SIGH. OK so now I am going to get an appeal together. I need help from those of you who have done this.
What needs to be included in the packet? How much information did you send?
Is more better or do you think their eyes glaze over if you send too much?
Any help would be appreciated greatly!

I have also called TBI and asked that Dr Blumenthal be apprised of this and asked if there were any other options for me at this time. I cant but help believe that ADR will be approved in the near future and maybe just maybe they have something that could help me hold off til then.


Thanks
Kim

[ESL]

did they tell you the grounds for the denial...tha would be a good place to start.

[ESL]

kim

having gone thru what you just did last year, i might be able to help you.....leave me an email or phone number....I will reach out to you.

[Kim]

They stated as did the original letter from the insurance company that ADR was still considered investigational and experimental at this time according to their criteria that is why they denied it. I challenged it through HR since our ins is self funded and hoped they would over ride it but didnt. The underwriters and the panel with the company that my hubby works for agreed with Great West on this. They would not give me an answer when I questioned why it was still considered experimental when FDA approval had been granted in October. All I was told was I had the right to appeal and to send a letter to the Benefits Director. Hubby happens to be in San Antonio right now in a new training class and plans to phone the Benefits Director and see if he can talk to him in person while he is there and see if we can get anywhere with him.
Kim

[cavalib]

I know I said I wasn't going to appeal, but my whole family is upset with me because I won't "give it a try." So now I am going to appeal the denial.; Can anyone give me some info on what I need to do? What are the chances my ins. company is actually going to change their mind? I have gathered every medical record I have from every doctor I have seen for my back over the last 7 years. Is that helpful?

[gary]

2 level prodisc under trials, santa monica ca....under PacificCare PPO.
10-20% my share, still huge amount compared to
what you are prepared for, along with increased
premiums, i paid more than some going to germany
or other foreign lands

[paulam310]

I received a 3 level adr 12-7-04, Blue Cross PPO approved me without question. I didn't realize that insurance companies were not approving; I feel like it's awful not to approve such surgeries. Keep fighting 'till you get what you need!

[Rein]

Originally posted by paulam310:
I received a 3 level adr 12-7-04, Blue Cross PPO approved me without question. I didn't realize that insurance companies were not approving; I feel like it's awful not to approve such surgeries. Keep fighting 'till you get what you need! Paulam310: For a lot of this, the issue of insurance is the prime reason we are not on the road to recovery. It would help a lot for you to post more details of your case here in this thread, even though you have posted elsewhere on a couple of the details.

Speaking of those details, you mention elsewhere that your surgeon was Dr. Lauryssen and you received the ProDisc. The fact that any insurance, and BCBS in particular, paid for this at this time (without appeal!!!) is astounding, given the fact that the ProDisc has not been FDA approved yet. If I'm not wrong, the ProDisc initial study was closed last October or thereabouts, so I'm assuming your procedure was part of the continuing access availability that has been allowed, and so the discs themselves were supplied free by Synthes. This still leaves the rest of the costs of surgery, hospitalization, etc.. Is it possible that you misspoke, and your discs are Charite? This would explain a lot.

Also, it would help to know if your insurance group is self-insured, to what extent, and how many members it has. Also, for those of us who do not know your doctor (or didn't see your other posts), it would help to mention the facility (and possibly other doctors) with which he is associated.

[Eddie_G]

Has anyone here had any dealings with Liberty Mutual (specifically Workers Comp)? Do they seem to manifest any socially redeeming characteristics? Or should I prepare for a fight?

Don't we have enough problems without having to worry about OUR OWN insurance companies screwing us over, making us jump through hoops ect...?

[paulam310]

Rein, let me try and clarify my surgeries and insurance. I received a diskectomy from Dr. Lauryssen 11-03 at C6. Then I received a 3 level prodisc from Dr. Delamarter 12-04 at C4-7. PPO stands for participating provider organization. I bought the insurance myself as a self-employed person. My first surgery was at Cedars and the second one was at St. John's, both in L.A. which is where I live. Since the prodisc is still in a trial all the discs were free, I believe that is the rule until the FDA approves the disc. Hope that answers all your questions.

[chuxk79]

KAISER a Chance
I called kaiser Customer Care about my 3 prodisc
surgery in Jan 05 and they sent me an emergency
form to fill out which I did and I provided some info on my surgery with Dr.Bertagnoli.
I thought I would get an immediate turn down
answer but they sent me a letter wanting copies
of my airline tickets,Doctors Report, and proof of payments.
I'm preparing to take my time and write a outlined letter regarding my surgery but I personally think it will all boil down to how the word "Emergency" is defined.
Kaisers handbook says an emergency medical condition is a medical or physchiatric condition
that manifests itself by accute symptoms of sufficient severity ( including severe pain)such
that you could reasonably expect the absence of
immediate medical attention to result in serious jeopardy to your health, serious impairment to your bodily functions, or serious dysfunction of
any bodily organ or part. (whew thats the most I ever typed) I personally think that being in years of pain and depression and once in a while
feeling suicidal from 24 hour a day pain should surelly qualify. I'LL KEEP YOU ALL POSTED
HOPEFULLY I WILL COLLECT SOME OF MY $46,000.00
Chuck Dobovsky

[paulam310]

Mark, you are correct. I received a 3 level cervical prodisc 12-04. I was the third person in the US to receive it.

[Mrowe]

My husband has DDD L5-S1. He is 38 years old and cannot do anything because of his pain. He is on heavy medication. It has been years since he has been able to function normally. Our insurance company, Humana, recently turned him down for ADR. They said it was still experimental in nature. Anyone have any suggestions for us in the appeal?

[NCFUSED]

Mrowe,
I am exactly the same age as your husband and same condition including heavy meds. I lost all of my appeals (3) w/ UHC and my employers benefits commitee. Your best bet would be to find out if your insurance is self funded by your employer or fully funded by the Ins. Company. If the later, you can appeal to the state, if self funded, his employer has final say, as did mine.

[Mrowe]

I believe they are self funded. He actually is retired - disability due to his back. It began with a back injury and now we also have a worker's comp lawsuit going. They paid for 2 years worth of medicine and doctor visits, then they decided they had paid "enough". I highly doubt whether the company would ok his surgery then, considering the lawsuit and all. Did you end up having fusion? I think that will be the doctor's suggestion. The problem is that his 3 bottom disks are all bad, just L5-S1 is the worst. So he may have to have 3 fused.

[NCFUSED]

I have a real bad DDD at l5-s1 and slight DD at L4-L5. Ive opted for fusion at L5-S1 and going to wait out the other. I am hoping ADR will be more widely "covered" by insurance at the point that I will need it.
Im working on scheduling fusion surgery right now...

[Mrowe]

Thank you for your help. My husband just heard back from the doctor and he will also be going for fusion. The doctor said we could appeal, but it would take 3 months and most likely get the same answer. Good luck to you!

[NCFUSED]

Best of Luck to your husband and yourself also.... As I know you are suffering along with him (I know my wife puts up with a lot lately)...
People tend to forget that our spouse's suffer along with us....

[Rein]

Originally posted by paulam310: (and edited by Rein)
I received a 3 level cervical ProDisc from Dr. Delamarter 12-04 at C4-7. I was the third person in the US to receive it. I bought the insurance (BCBS PPO) myself as a self-employed person. My first surgery was at St. John's in L.A. where I live. Since the ProDisc is still in a trial all the discs were free.g I subsequently emailed Paula about some details of her post and she was gracious enough to allow me to post her reply:

�05/05/01
Rein, I wanted to add that insurance, after the deductible and co-pays were met, paid all hospital charges. My doctor is out of network so of course I had to pay him a higher fee, that would have happened no matter what kind of surgery I had. So insurance paid my doctor their blue cross ppo rate, then I was responsible for anything over that.�

As a matter of fact, unless BCBS PPO plan for California is different than Massachusetts (which is certainly very possible), for a member to use out-of-network providers first the deductible ($250/member/year) must be paid, then the co-pay, which equals 20% of the allowed charges up to $1000 per member per calendar year. This means the total should have come to $1250, if my math is correct.

What completely baffles me is why Paula�s surgery was paid for by BCBS if her procedure is still in FDA testing (which the ProDisc-C still is), whether it had anything to do with the fact that she is totally self-insured or whether Dr. Delamarter has some clout with the local BCBS providers due to their experiences with previous ProDisc cases. Why in the world would BCBS pay (without even escalating to the appeals process, yet!) if they�re still denying some people the Charite, which *is* FDA approved?!! This is crazy!

Paula, I�m still extremely happy for you, that you were able to obtain this procedure with no hassles whatsoever, and hope and pray that you develop no complications. The fact that most of the rest of us are struggling against the odds for the same thing should in no way diminish your feeling of success. You go, girl! http://adrsupport.org/groupee_common/emoticons/icon_smile.gif

If anyone has any insight into the questions I�ve posed, please, PLEASE!, either post some answers or email me direct! Thanks.

[ernie]

I am new to this , so if I make a mistake, please correct me. My daughter, age 33 has been laying on the floor 3 years,FDA has approved 3 level prodisc at PENNA HOSPITAL PHILA, TEXAX BACK SAYS SHE NEEDS 3 LEVEL. AETNA WILL NOT PAY. HAS AETNA PAID FOR ANY ONE ELSE. Thanks for the help
Up date may 13, 2005 Penna Hospital In philadelphia,
June 22,05 3 level PRO-DISC, COST 49,300- INS NOTHING, ON 3RD APPEAL AETNA! RESULTS 11 WEEKS POST OP- 100% PAIN FREE, OVER HER LIFE SPAN COME OUT TO 856.00 PER YEAR. pOLITICIANS ARE JUST THAT, NO GOOD
KEEP ON FIGHTING, WE ARE GOING FOR OUR THIRD APPEAL. SHE GOES BACK TO WORK SEPT 21,05 2" TALLER AND 100% PAIN FREE
gtOOD LUCH TO ALL, AND THANKS FOR A GOOD SIT.

[David]

At this point in time, I believe that Aetna has approved ADR as medically necessary for one level, but not for three...

http://www.aetna.com/cpb/data/CPBA0591.html

(that being said, perhaps someone else could prove me wrong)

David

[NCFUSED]

David you are correct, Aetna will pay for 1 level Charite, as the FDA has only approved 1 Level using the Charite device at this time.

Multi-level operations using Charite and other devices are only in FDA Clinical trials at the moment.

[paulam310]

Rein, I wish that I had some insights to post for you, but I don't. All I can say is that Delamarter's accounting department told me even before my surgery what my insurance company would pay which means they had had experience with BC PPO paying for these adr surgeries before. The only person I owed money to after my surgery was the doctor because he was out of network. Good luck, don't stop fighting for the surgery, it is worth it.

[hucky]

Hi,

I'm wondering if there are any Australian Third Party Insurance ADR candidates out there. I've been approved for a discectomy and fusion on the C6/7, but have been denied ADR as it's considered as "experimental". My private health insurance will pay for it - so can't understand why one insurance co considers it experimental and the other not. If my 3rd party insurance won't approve after appeal - at least I can go with my private insurance - but will be approx. $4,000 out of pocket!

If there are any other Ozzie ADR approved 3rd Party candidates out there - would you let me know how you got their approval.

Hucky

[Eddie_G]

Liberty Mutual anyone??? ....ANYONE?????

[walker]

I just want to thank everyone who has contributed to this thread. LOOK-4 pages of great information.

My doctor's office called me this week to check on my progress with the BC/BS of Oklahoma. I have been calling the insurance co. several times a week every week. As it turns out, doc's office never sent a letter to start the process. Quote from my dr's office: "Everyone thought that someone else was taking care of it." It is May 13 and my precert denial was March 4. Talk about losing faith in someone.

I'm just getting by right now. I appreciate the support from the members here that have been talking to me along the way. Without you and this website--I probably would have settled for soemthing I really don't want. Thanks guys. Thanks Nikki.

All you insurance warriors----STAY WITH IT!!!

[Kim]

Nikki
Hang in there! Been there done that. I have had to check up on the docs office, ins company, HR etc every step of the way to make sure they are doing what they were supposed to do. You would be appalled to know HOW many times I got the story you did.
You have to check and double check and triple check. Call the docs office and aggravate the bejeebers out of them. The SQUEAKY wheel gets the grease. It appalls me that we have to do this. I have worked in the medical profession in one aspect or another for over 20 years and I am ashamed of the medical care that we get at times.
If you need to talk please feel free to PM me. We have to work together.

[walker]

I mean thanks to Nikki. She has been an angel in my quest for more information and new hope.

Kim, I am sorry that we have to be the squeaky wheels. It's funny you said that because that's exactly what I told my doc I was gonna be.

I have kept track of names and date of the people I have talked to at the ins co and doc's office. This has already come in handy. I have a file two inches thick on the info I have acquired. Most of it came from here in one way or another. After visiting with the folks at this website, I have only become more determined and more informed.

My name is LaJeana, and I am sick and tired of being sick and tired! :-)

[Kim]

OOOps sorry about the name thing http://adrsupport.org/groupee_common/emoticons/icon_frown.gif that goes to show you how you can mess up when you are reading too much too quick.
LaJeana keep up the work. Yes I take names and always ask for names when I call the drs office. I find its a great help to talk to the same person as much as I can. If they remember you its much easier to get something done. Also if they know you will call and frequently lol they will get on the ball and get what you need done.
I am sick and tired too and its a shame we have to do this. Hopefully at least if nothing else we will be helping those who come after us have an easier time of getting this surgery done. I have found this site and the people on it more valuable than gold in my quest to get my back taken care of. I would be lost without the kind folks here who have gone before me. I just hope I can pay it forward to the next one in line.
Kim

[Rein]

It's that time of year where my wife and I can change insurance carriers at her place of work. Since it's obvious Blue Cross is totally random and there's a good chance they may not cover my ADR until well into next year (unless I can sort out an arrangement similar to Rich's), anyone had any contact with Harvard Pilgrim of Massachusetts?

[Nichole]

LaJeana You are so welcome. There have been many angels before me who have helped me trudge thru my own hell and I am proud to help in any way possible. Keep me posted definately about your progress and if there is anything else I can do to help. Research, phone calls anything.

Nikki

[Jim M2]

Hi,
Rein has asked me to post more about my insurance experience with ADR.

Pre-surgery Regence Blue Shield in Washington told me they pay only according to accepted diagnostic and procedure codes. They would not pay for ADR, which in 2003 was not approved. I did not bother to fight them. I did not have the energy. I had no documentation to offer. I had some money so I paid for the surgery in Germany.

Several weeks after surgery I submitted a written appeal (SEE THE LETTER BELOW THE ASTERICKS) requesting to be reimbursed for medical costs. About 50 pages of doctors office notes, radiology reports and all of the bills and descriptions of services from Germany in German were attached to the appeal. Several weeks later I received a check for 89% of the total.

It makes me angry and frustrated to know you are going through this while you are so sick.

Best wishes,
Jim

*****************************
October 24, 2003

Regence Blue Shield and The Company (my employer)
<note: Regence's address for appeals was here>

Dear Appeals Specialist,

PUPPOSE
I am appealing to Regence Blue Shield and the Company to reimburse me for medical costs of artificial disc replacement (ADR) that were incurred in August and September of 2003 in Munich, Germany. Please respond to this request in writing to the undersigned.


INTRODUCTION
In May 2002 I developed chronic, severely debilitating low back pain. In search of relief I visited numerous physicians including a pain management doctor, orthopedic surgeons and neurosurgeons. MRI, X-rays and CAT-Myelo diagnostics all confirmed a collapsed lumbar disc at L5S1. Medications, physical therapy, exercise and severe restriction of activities brought only limited reduction in pain levels. After months of research on the topics of spinal disorders, fusion and ADR I opted for ADR. In August 2003 I traveled to Munich, Germany and had ADR by Dr. Willem Zeegers at the Alpha Clinic.

LETTER OF MEDICAL NECESSITY
I am submitting this letter together with the writings of five surgeons as a Letter of Medical Necessity.

The first three writings are office notes from the U.S. surgeons who personally examined me in 2002 and 2003 prior to surgery. Their names are Dr. Villanueva, Dr. Schlitt and Dr. Krengel. Their office notes are attached. All three surgeons speak of spinal fusion as the primary option to be considered in my case for pain reduction and increased functionality if conservative treatment did not improve my condition.

The forth writing is from Dr. ML Whitworth. His writing is a matter of public record. It can be found online at the Massachusetts General Hospital Neurology discussion forum. A copy is attached. Dr. Whitworth feels "fusion is an archaic barbaric anachronism which is only necessary if there is significant spondylolisthesis or foraminal stenosis..." In the attached writing he goes on to justify this statement, to advocate ADR under protocol and to explain that many surgeons continue to perform fusions for monetary reasons.

The fifth writing is a diagnostic report on my condition from Dr. Zeegers of the Alpha Clinic in Munich, Germany. Dr. Zeegers is the world's leading ADR surgeon. He has performed over 1000 implant surgeries since the 1980s. After examining my MRI, CAT-Myelo, x-rays, radiology reports and patient questionnaire he concluded that I was a good candidate for ADR, pending a personal examination in Munich.

Beyond these writings I read extensively on the topics of spinal disorders, spinal fusion and ADR to ascertain my understanding of the risks and potential benefits of these two medical procedures. My conclusion matched that of Dr. Whitworth and Dr. Zeegers. It was my conclusion that ADR was statistically superior to fusion for pain reduction, improved functionality and better prospects for long term health.

ADDITIONAL CONSIDERATIONS
1) ADR at Alpha Clinic costs $20K. It is my understanding that ADR under FDA trials in the U.S. costs $60K. It is my understanding that costs for spinal fusion in the U.S. range from $50K to $80K.

2) Dr. Zeegers is the world's leader in ADR. He has performed over 1000 implants of the SB Charite artificial disc since the 1980s.

3) Surgery was needed in the near term to relieve pain, prevent degeneration of facet joints and to eliminate potential for nerve damage.

4) It stands to reason that European surgeons performing ADR would have a higher success rate when compared to their lesser experienced U.S. counterparts.

MEDICAL ACTIVITIES AT ALPHA KLINIK
On 18-Aug-2003 I departed for Munich, Germany. On 21-Aug-2003 I was personally examined by dr. Zeegers at the Alpha Clinic. X-rays were made of the lumbar spine and discography was performed on levels L2S1. A complete physical examination which included chest x-ray, EKG, breathing and blood test, was performed. I was fitted with a custom made lumbar corset. On 22-Aug-2003 a Charite artificial disc was implanted at the L5S1 level of my spine. I spent four nights in the Alpha Clinic hospital before being released on 26-Aug-2003. Just prior to release from the clinic more x-rays were taken to verify placement of the implant. An ultrasound test was conducted to verify the absence of thrombosis. In the two weeks after surgery I received two more personal examinations by Dr. Zeegers and five sessions of physical therapy at the Alpha Clinic.


SUMMARY OF MEDICAL CHARGES AND PAYMENTS
Receipts, exchange rates, accounting and descriptions of services are attached. Payments were made by wire transfer and VISA card. Approximately $6K of travel expenses and lodging have been borne by myself.

CHARGES
ITEM EURO
Brace Shop 1,000.00
Anesthesiology 1,540.66
Medical Exam 300.00
Alpha Clinic 10,389.90
Surgeon 4,371.52
Ultrasound 88.27
Physical Therapy* 450.70
-------------------------
Total 18,141.05

PAYMENTS
ITEM EURO US DOLLAR
Wire Transfer 15,256.97 17,250.00
VISA 1,000.00 1,101.76
VISA 1,345.11 1,481.98
VISA 88.27 97.25
VISA* 350.56 393.34
VISA* 90.14 101.14
-------------------------------------
Totals 18,131.05 20,425.47

*Discrepancy between charges and payments for physical therapy appears to be a clerical error where Alpha Klinik billed my VISA 350.56 Euro instead of 360.56 Euro.

CONCLUSION
Regence BS and the Company are requested to pay $20,425.47 to the employee to meet their obligations as his health care provider. Please respond to this request in writing to the undersigned.

Sincerely,

Jim M2

[Rein]

Right on, Jim!!! Thank you very much for sharing with us that extensive and very detailed information. This is exactly the kind of stuff many people need to get what they deserve.

[Jim M2]

Rein,

I hate to disappoint but I've PM'ed this appeal letter to some others. They were not successful in their appeals.

In my case the Company was self insured. Blue Shield was contracted by the company only to administer the plan. Appeals were probably decided by the company since it was their money.

That said, the appeals letter and it's attachments were complete enough to satisfy the decision makers.

Jim

[Kat]

I am pretty new here and have UHC insurance. They denied my ADR and I am currently on my 1st appeal. Awesome letter Jim...I may use that on my next appeal. There are some VERY interesting things going on here in St Louis regarding UHC though. 3 major hospitals in the area are no longer going to accept UHC insurance in a protest. It is my understanding, that UHC is accused of "steering" patients towards certain doctors. Has anyone in other parts of the country heard of this???

Since they denied FDA approved ADR, makes me wonder if they aren't "steering" patients towards certain medical procedures....Hmmmmm, I wonder.

Kat

[amanda]

Hi Kat,
UHC denied my husband's L5-S1 ADR thru Texas Back. I appealed it (with 120 pages of documentation). They just denied ADR again. I spoke with a supervisor yesterday who requested that I resubmit the appeal to her directly. She received it today. We'll see what happens. If anything good happens, I'll let you know. Jim's letter is awesome. I wish we could get "60 Minutes" or similar involved to expose the extreme pain, suffering & grief of patients denied by United Health Care & others...something to garner public sympathey awareness on the subject.

[David]

UHC here as well, although my doctor is waiting for the results of my 2nd discogram before oficially submitting his L4-L5 charite pre-certification request.

He seems to think that we won't have any issues, although I am extremely skeptical. Should find out in 3 or so weeks (discogram is 17-JUN).

David

[Juli]

I also have UHC. I will be submitting my pre-certification after my 2nd opinion with Dr. Bitan on Friday. I was recommended for a two level at L3-L4 and L4-L5 by Dr Zeegers last week. I am going to submit both next week(assuming they are in agreement) and cross my fingers (toes, etc..). I will post how that goes and am interested to see how you guys that
also have UHC fare. So far, no one I know with UHC has been approved. At this point, I am assuming I will be paying for it so expect to be having the surgery in Munich in the fall.

[Rein]

Here's a member from Tennessee who managed to get BCBS to cover his ADR at TBI:

posted June 06, 2005 09:57 PM ��� �� �� �� � � �� ��
I am leaving tommorow morning for Plano, Tx. to have one level ADR L5S1 to be performed by Dr. Blumenthal at the Texas Back Institute. My BCBS is covering the procedure and my hospital stay. This is one surgery that i am actually looking forward to having. I want to thank some of the people who post on ADR forum, especially my friend who also lives in TN. for there support and advice. My friend in Tn. was very supportive and helpful.
Sincerely, JF110

Here's a link to his post:

http://www.adrsupport.org/private-cgi-bin/ultimatebb.cg...;t=000541;p=1#000000 (http://www.adrsupport.org/private-cgi-bin/ultimatebb.cgi?ubb=get_topic;f=1;t=000541;p=1#0000 00)

[sfmcfar]

FWIW...

My doc has told me that UHC has been the worst when it comes to approving ADR. I have MAMSI, which is owned by UHC, and I don't believe they even looked at my appeal before they denied it. What *really* gets me is that my appeal (as I've stated as couple of times in the forum) was based solely on the regulation that prevents Federal Employee insurers from labeling an FDA-approved product as experimental. In my denial letter, they never addressed the regulation - never even mentioned it. Basically, they completely blew me off.

-stan

[walker]

New news from my doctor's office yesterday concerning my first appeal:

BCBS has notified my doc's office that they have received and reviewed my appeal information submitted solely from my doctor's office. They advised us to "hold out" till July 1, 2005 and resubmit my claim (precert) to them. The AMA has new codes for the ADR procedure that will take affect then. Right now, the codes submitted are not specific to this process.

Well, BCBS is not saying that they will give me the go ahead with the new codes-- but it is the most (almost) positive thing I have heard from them to date. I know there has been a lot of talk about coding in this forum. I have followed it all. I also realize that bcbs may just be wasting some more of my time. Only time will tell. I have been checking into other ways to get this done and will not hold my breath for bcbs to come through.

I will post again after I hear something after 7-1-05. I have only been waiting since the end of February!!!!!!!

[Juli]

Interesting news Walker, thanks. I have my discogram and some kind of reversal test on the 28th and then my doctor will be submitting the pre-cert. Is it possible for once that my timing might be good?
I will not get too excited, but that is something good to hear!

[Jim M2]

bump