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go*big*red 06-07-2006 08:39 AM

Okay - my Panel Review is scheduled for today at 1:00 CST which by my calculations is 12:00 MDT. Wish me luck!

David 06-07-2006 08:58 AM

Veil Gluck!


go*big*red 06-07-2006 12:51 PM

Well, that went well - - - - NOT !!!

The Dr. on the panel said that UHC HAS NOT approved ADR to date and wasn't sure where I got my information, but it was not correct.

They already had their mind made up. The deal is that the FDA has approved the device with some stipulations. ONLY if the patient has not had previous surgeries - which they consider my 4 level IDET a surgical proceedure (what a friggin joke that was anyway!) and of course my fusion at L5/S1. And, FDA approval only if there is only one disc involved. He stated that all my lumbar discs are involved and that if they approved it, that Pacificare would be liable - that I could sue them.

And, he stated that 60% of these procedures have had bad outcomes - i.e. revision surgeries which are very dangerous and/or spontaneous fusion of the devise???? I've never heard of that.

Anyway, I'm screwed. Plain and simple. They will notify me of the decision, but what chance do I have, really? They didn't allow the Charite' people to be involved in the call so she couldn't talk about multiple level surgeries already performed., etc. etc. etc.

What's the friggin use?

sahuaro 06-07-2006 10:07 PM

I am so sorry about this outcome for you. This was not unexpected, sad to say. Was your reviewer a physician? Obviously, whoever it was had a pre-scripted response. As I've indicated, as a provider, I have learned that when I get a message to call re pre-certification for a patient, it means the answer is "no." Is there another recourse, i.e., another appeal level?

go*big*red 06-09-2006 10:14 AM


Really sorry for the spew and vulgarity that was implied.

Thank you so much, David for the well wishes and sahuaro for your insight. Some things have transpired since my review and some things were discussed during the review that I didn't mention.

First off, I did mention the Dr. stating that my information on UHC approving at that time 3 discs (or was it 4?) was erroneous. That UHC stated that they had not. And, then found out looking at the link after the call that they had infact approved 6 to date - one in Colorado.

Secondly, I also stated his info about the FDA approving the Charite' only under certain stipulations - two of which I fail at 1) only one disc being bad and 2) no prior surgeries. He stated from my file that all my discs are bad and that I had 2 previous surgeries (actually, I had had 3 if you count the hardware removal).

So....I asked him if UHC granted pre-auth and ultimately covered this surgery, against the recommendations of the FDA, what then. He promptly stated that they would have liability if it went south. I asked him what that meant and he repeated it. What an a$$. Anyway, so I asked him if I could sue UHC and he said absolutely - that that would be their liability.

I then said, through tears (that so fries me when I get emotional like that) that I guess I had nothing more to say. The facilitator promptly dismissed me stating that they would discuss and I would receive a letter with their decision.

So.....that said - I called Jane, my Charite' rep and she said on his two points of my not being a good candidate that he had me there.

She also said that Dr. P had submitted everything with "off label" use of the disc meaning that I don't qualify perfectly. That is making the appeal process all that much harder, but had to be done that way. She commended me for going the distance and that we could still do an external review but did not sound very optimistic.

I then called Dr. P's office and spoke with his assistant. She, on the other hand, said that what the Dr. spoke of was only for the trials and that the FDA approved the disc with none of those requirements - that it was to each surgeon's descretion.

Sorry for the long discertation! Geeze! Anyway - (not done yet) so now I have two stories. She also asked what Jane had said. I told her but she also said she would call Jane and get back with me as by this time, the faucets were turned on again. I was so darn discouraged.

Next thing I know, Dr. P's office is calling to set up an appt. asap as Dr. P wants to discuss "surgical options". Not sure what that means, but encouraging none the less I think. So, that appt. is today at 12.

And, I have a call in to the FDA consumer dept. to get the actual documentation on the Charite's approval. I'm thinking I'm catching this Dr. on several lies and when I get that documentation, I am once again getting the Colorado Dept. of Ins. involved.

This just so fries me as I think they tried to bully me (which worked - not allowing anyone with me in my review that I wanted) and I'm just not going to stand for it. It may or may not help me, but would indeed help the next "me" in this whole process from hell!

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