State Board Denies ADR

[mmarsh]

Well got a call from the state dept of ins and they agree with the ins co that ADR is experimental! I guess all you recipients and your docs are bucking the powers that be! You're all so lucky that your coverage has joined the 21st century and is not stuck using leeches! Now I'll be paying out of pocket and no recourse except the courts. Hope others have better results than I did.

Missy

[ChainedJane]

Awwwwww Missy I am So Sorry to hear that...So UNFAIR! I just can not wrap my head around the fact that BCBS can ok this surgery in their other states. And you are a case study in yourself having had the fusion. I really hope you have the energy and your lawyer can just sue the pants off them! Your appeals where superiorly written.....I don't think you could have done any better!(((Hugs)))I will say a prayer for you.I hope you keep up the good fight!

Janey

[Harrison]

Missy,

Can you explain a bit more? Did you have your appeal reviewed by an independent third party reviewer? This is another process that you have a right to pursue. In fact, the overturn rate may be up to 50% in some states...

[sahuaro]

My appeal was also turned down at the state insurance board level--over HealthNet's objections, they did send it to an anonymous reviewer identified only as being an orthopedic spine surgeon associated with a medical school. His comments indicated he either didn't read my appeal or chose to ignore all the points I made, but his opinion was that the procedure is experimental and according to my insurance contract, HealthNet was justified in denying the surgery.

[mmarsh]

Rich

It was the independent hearing. It was to the CA state dept of ins, they call it an independent medical review. I have not seen the denials yet, they are in the mail, but apparently the 3 docs, one NS, one ortho and one PM were not impressed by my argument. I refuted the definition of "investigational and experimental" and showed them loads of articles in favor of CADR. I'm guessing that the 3 docs were old school and don't know enough about ADR to do it themselves, so they rule it all "experimental". I'll fill in more details as the paperwork reaches me. I thought I wrote a very well thought out argument and backed it up with peer reviewed articles and expert opinion as they required. Go figures! Maybe CA is not one of those 50% states. They don't have to tell me the percentages of overturned denials. MORE SECRETS!!!!!!!!!

Missy

[mmarsh]

Janey

Thanks for the hugs! I really needed them!

Sahuaro

I'm thinking that my docs were equally unimpressed or didn't really read what I wrote. I'll keep you posted.

Missy

[LBP]

Missy,

Sorry you had the same experience as me a few years ago. (also CA) Seems nothing has changed. I was just as frustrated as you. You just have to find a new angle to get ADR coverage. I really really recommend finding a way to get Aetna ins.

LBP

[Terry]

Missy:

I am so sorry to hear about your denial. I hope you continue to fight this as there is no good reason to deny this surgery other than greed as they don't want to pay; period. But please keep paying your insurance premiums and remember; "We love you; the customer." Enough people need to stand up to them and punch them in the nose. It's the only way you get their attention.

Hang in there and know that we support you and are there for you.

Terry Newton

[mmarsh]

LBP

Sad that things have changed so little over the years isn't it? It's too bad these docs don't keep up with the latest technology after they leave practice and then decide that something is "experimental" when thousands of surgeons are using the devices. In November when I can change ins cos, believe me I'll be checking on the current status of cos okaying ADR!

Terry

Thanks for your kind words. I'll have to take them to court now as that was my last gasp for appeals. I wrote such a good one, too!

Missy

[epiphaknee]

sahuaro

I wonder if you can file a Freedom of Information Act ("FOIA") request to determine the identity of the anonymous reviewer. It seems to smack of lack of due process (violation of Constitutional law), if I don't even know the name or credentials of my reviewer. I wonder if you would consider checking with your local law schools UofA or ASU and see if they have a legal clinic that would help you with the FOIA request.

Of course you're going to get denied by an anonymous reviewer! Does anyone think he/she would be hired again, if they agreed with your ADR appeal?

[sahuaro]

epiphaknee:
You are absolutely right that an anonymous reviewer is free to deny treatment without any consequence. In fact, I think Arizona statute requires that I be given the name and credentials of the reviewer. Since this was an "independent review" through the State Department of Insurance, it was quite disheartening. But there is no avenue to protest--that I know of--since this level of appeal is the final and decisive level.
As far as I know, the only avenue left is a lawsuit and I just don't have the energy for that--and I had enough of lawyers with the personal injury suit in which State Farm's lawyer got away with outrageous behavior.
Do I sound defeated????

[ans]

I'm sorry to hear all this. I was turned down for an ENT procedure by a proctologist. http://adrsupport.org/groupee_common/emoticons/icon_frown.gif

[Terry]

Sahurao:

You had a personal injury suit against State Farm? That's who I sued and the lawyer was an absolute A--Hole. He was offensive as they come to try to disarm me. I am a professional court witness and am on the stand often. I do not intimidate easily and never missed a beat when he threw shots at me. The adjuster knew I would be a nightmare in court and had me paid. They knew I had my facts straight and would not fold under pressure on the stand. I loved it.

I absolutely hate State farm with a passion and would sue them for general purpose any time I could.

Terry Newton

[sahuaro]

Terry:
Wish you could have been at my trial, perhaps even standing in for my wimp of a lawyer who was no match for the State Farm lawyer...

[Terry]

I truly hate State Farm. I used to have them as my main carrier for my house, cars, jewelry riders, whole life plans, etc. Then my wife got rear ended by a lady going about 40 MPH after my wife had pulled over, and stopped, for an ambulance. It broke my wife's back in three places and State Farm was not like a good neighbor. We had this drag out for a year before they settled. I never got a lawyer involved in that one and handled it myself. I knew what the lady had for a liability policy and knew what I'd get if I got a lawyer involved and stuck to that amount. They beat me up every step of the way. When I went in for my check from them I told them to drop all of my coverage as I had went out a week before and got a new carrier as I would not stick with a company that treated us like such garbage. I got the amount I wanted also.

Then my bicycle accident is with a homeowner's dog who slams in to the front wheel of my bicycle causing me to catapult end over end causing significant damage to my shoulder and spine. And to find the homeowner had State Farm set me off royally.

It was fun doing battle with them. I love pompous attorneys who believe their poop doesn't stink. A bunch of Sharks.

I am so sorry you had a lousy attorney. State Farm is notorious for hiring the nastiest sharks around. Did you get anything out of them at all or they sided with State Farm? If so, that is the biggest injustice I have heard of. State Farm's profits read like a Third World Country's Balance Sheet. YUK!

Terry Newton

[ChainedJane]

Terry,

Awwww.....was the puppy ok?

Sorry I am a huge animal lover and pet groomer!Irresponsible pet owners is a big pet peeve of mine! Sorry to get off topic!

[sahuaro]

Terry:
Let's just say that the jury award did not cover all of my medical expenses to the date of the trial, let alone compensation for pain and suffering and lost income. And 1/3 of the award went to my lawyer...The State Farm attorney was promoted to partner in his law firm and his website now advertises that he argues against "unnecessary surgery, abuse of physical therapy," etc--all of the stuff he pulled (without any witnesses testifying to those arguments!) at the trial. Plus, the jury was not informed that he was the insurance attorney, not the attorney for the guy who rammed his car into mine.

[ans]

Where are the "whistleblowers" on this re: "60 Minutes", etc.

[Terry]

The "PUPPY" was a 100 Pound German Shepard / Rottweiller and was stunned in the collision. He survived and fared far better than I did. I broke - he was dazed.

I am so sorry for the lousy settlement you got. I hate insurance companies as the deck is stacked in their favor. They can outlast and outspend all of us in a moments notice.

We will look back on these days as, the dark days of America, where corporations ruled at the expense of people.

Terry Newton

[ChainedJane]

Quote Terry-""I hate insurance companies as the deck is stacked in their favor. They can outlast and outspend all of us in a moments notice.

We will look back on these days as, the dark days of America, where corporations ruled at the expense of people.""

I so begrudgingly agree and how well put!