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.

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

Thanks Cindee. Congrats!

Anyone else wish to contribute?

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.

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

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

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.

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?

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

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.

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....

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

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!

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.

"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.

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?

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

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

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".

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.

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.

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?

Good points; rather sobering.

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

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.

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.

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

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

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).

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

Juli
DDD L3-L4 on down since 1990

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....

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

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

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.

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...icon_smile.gif but I do believe the insurance companies must be on the verge of capitulating.

CIGNA HMO.

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

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...icon_smile.gif

Hi Bmills:

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

Thanks.

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

Brady

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?