Blue Cross Blue Shield ADR Coverage

[stuschulz]

Has anyone with Blue Cross Blue Shield of Illinois, Texas, New Mexico or Oklahoma had their lumbar ADR covered?

Thanks,

Stuart

[epiphaknee]

See Blue Cross Blue Shield Policy 127:

http://www.regence.com/trgmedpol/surgery/sur127.html

But also see: http://www.globalpatientnetwork.com/news/***news-wsj.shtml

Insurers have taken a mixed view of the device. Kaiser Permanente, the California-based health maintenance organization, endorsed the Charité last November after requests by its doctors but the Blue Cross and Blue Shield Association concluded there isn't enough evidence that the device works. Most of the nation's 40 independently owned Blue Cross and Blue Shield plans are following that advice.

One exception is Horizon Blue Cross Blue Shield of New Jersey. It decided the Charité is right for some patients and doesn't cost much more than spinal fusion, says senior medical director Stanley Harris. He puts the cost of the procedure, including doctor and hospital fees, at $67,000 per patient. J&J says a more typical figure is $35,000 to $45,000.

[djscal]

I got Regence Blue Shield to pay for my ADR surgery after a pretty viscous fight which involved 3 appeals, hiring an attorney for thousands of dollars and hundreds of hours of my time. Even after they reversed their decision and paid, they clearly stated in their letter to me that my case was a one off special circumstances case and their policy was clearly not to pay for ADR.

My case is strange because they initially did pay and then attempted to rescind payment about 9 months after paying for the surgery. Insurance companies by law have one year to rescind payment for any reason of their choosing. An overzealous blue shield bean counter looking for career advancement must have thought that I would roll over and accept defeat and be intimidated by their b.s.; not so.

I wish you luck in your fight.

It is absolutely sickening what is going on in this country with respect to health insurance.

[robby]

djscal,

How many levels did you have done? I have been denied for 2 level and in the middle of the appeals process now.

Robby

[djscal]

One level, it's in my signature.

I hired the lawyer between my 2nd and 3rd level appeal (independent medical review) with the insurance company. Having him on the phone was priceless. The intimation was that we will sue the living hell out of you for punitive damages and intentional infliction of emotional distress if you don't get with the program. It worked. http://adrsupport.org/groupee_common/emoticons/icon_smile.gif

[robby]

Sorry....didn't read the signature....I have already spoken with my lawyer about this and he is ready to get involved when the time comes. Anthem Blue Cross Blue Sheild is my provider. Thanks for the giving me hope!

[djscal]

There is definately hope. To minimize cost with the attorney I recommend that you do as much work for him as possible. That includes printing out articles for him including your benefits manual and all of your correspondence with the insurance company including letters from doctors stating that this is the best course of treatment for you. Basically you do all of the leg work and he brings the firepower to the showdown. This is how I got away with only paying for 6 hrs of his time. I probably spent 100 hours to his 6.

Remember, they don't want to go to court as it is bad PR for them and very expensive so if you make them believe that you will sue they are more likely to back down. Everything is a negotiation - even with the insurance company.

It's a sickening thing to do, but try to think like them. What would you do in their situation? Answer: the most inexpensive possible solution. If that means paying to avoid a major lawsuit, they will probably do it. You could also team up with other ADRSupport members and file a class action suit. That will make them wake and pay attention.

I can't believe we are still talking about this issue in 2007 3 years after the Charite was FDA approved. (sic)

[D. Coley]

Please read my post about insurance approval recended a new way in the Big File forum!!!!

I thought I had won the fight and Blue Cross OKlahoma won!!

I have also talked to lots of other people that actually made the surgery date and then got stuck with ALL the bills afterward and have the insurance APPROVAL letter too.

The loop hole according to BC/BS is that the corporate offices send out the approval letters but ultimately the STATE offices (in-network ppo office) determine whether or not to pay....that's where the billing after the surgery goes to.

I'm angry but thanking the man above that my surgery was post poned several times and then cancelled by the surgeon because they (BC/BS) don't pay the bills and glad I didn't get stuck with them.

I would have become known as the BC/BS BOMBER if I would have got stuck with all the bills after the surgery AND having an approval letter AND paying $600. a month in premiums.

I now DONT TRUST ANYTHING THEY TELL ME!!!!!!!!!

[Don]

I have UHC and they do not cover ADR. But, I can switch to BCBS. I assumed it was BCBS of Michigan, but I checked and I would be covered by Horizen, BCBS of NJ. Any idea if that is really the case? They say that, but I have a feeling I would fall under the rules for BCBS of Michigan, becasue I live in Michigan. I'm going to make a few more calls to them, but wonder if anyone has any experience with them?

[QUOTE]Originally posted by Don:
I have UHC and they do not cover ADR. But, I can switch to BCBS. I assumed QUOTE]
Hi Don,

Do not waste your time with UHC if it is a PPO. I have spent 8 months battling insurance for nothing. In the end the HR director decided my health care! Also, if you switch to BCBS will they consider it pre-existing? Do not assume anything with insurance. They pull any shenanigans they can to NOT of pay.

[JFerg]

As a UHC member, unfortunately, I have also been denied 3x's for ADR. The last denial from UHC was because not only is L4 severely herniated but L3 is torn as well. Along with the standard information that ADR surgery doesn't have the usual track record blah, blah, blah.... I almost consented to a fusion at the Univ. Of Miami when, believe it or not, I heard the small, still, peaceable voice of God putting a name in my spirit. It was the name of a chiropractor that I saw in '87 when I twinged my back a little. So, I went to see her. UHC paid for a procedure called Manipulation Under Anesthesia (about $25,000)with no co-pay on my part. For 3 mornings at 1 hour at a time, they put me out (disabled my defense mechanisms)an ortho and 2 chiros just bent and twisted, pulled and turned, etc. I want to let you guys know that I've been pain-free since Jan. The hardest part for me has been getting off the narcs. This procedure gave me my life back. I'm in no position to recommend any procedure to anyone else, but for me it was a desperate time. I do yoga religiously, ahd when I feel the tightening up in the lower back, I stop what I'm doing and stretch for 5 minutes. I just wanted to share this with you guys since this board has given me such hope and motivation over the past 5 years of absolute chaos. Thanks.