United Healthcare Rejection
 

Hi All, I am new to the site as a poster, but have followed the forum for some time. In a far from shocking development from what I have read, UHC rejected my surgery for L5S1 Prodisc-L due to the experimental reasoning. We are appealing and I will post my findings. It certainly appears as though they have approved some of these based on the Charite website and other anecdotal evidence. If anyone has any info on UHC and this procedure please let me know and I will do the same.

Appeal Decision by Monday
 

I was told today that I would get the appeal decision decision by Monday, but realistically see little reason for hope. I would like for them to be honest regarding their reasoning, but that is pie in the sky also. I might respect them slightly more thought if they just admitted that they don't give a flying crapola about my health and it is all about the money.

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L5S1 Herniation and Annular tear, over 10 epidurals, DDD, 2 discograms (positive), Countless attempts at conservative therapy including losing 30 lbs.

United healthcare response
 

Hi Everyone, I thought some of you might be interested in the response of UHC regarding Prodisc-L. The meat of it is as follows:

"The FDA has the final say as to the Prodisc-L being effective for long term treatment, and asked its company to conduct a study to that effect. That company has not yet been able to show long term effectiveness of the Prodisc-L total disc arthroplasty. The FDA reviews all the studies and trials and has not found as yet any well-conducted or cohort trials to support long term effectiveness."

Anyone have any comment on that?

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L5S1 Herniation and Annular tear
Over 10 epidurals,
DDD, 2 discograms (positive),
Countless attempts at conservative therapy.
Tentative Surgery date 5-26-09 (very much in jeopardy!)
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UHC Reviewing Surgeon is Plastic Surgeon!
 

I got my second appeal rejection from United Healthcare and it read as follows: "All of your supporting documentation was referred to a board certified Care Management Medical Director, "NAME", M.D. specializing in Plastic Surgery, not previously involved in this decision, for review". They were obviously far more concerned with pointing out that he wasn't in the room the first time they rejected ADR then recognizing that he is a PLASTIC SURGEON. It's almost funny. Almost. And to think all this time I should have been seeing a Plastic Surgeon for my back problems. Who knew?

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L5S1 Herniation and Annular tear
Over 10 epidurals,
DDD, 2 discograms (positive),
Countless attempts at conservative therapy.
Surgery date 5-26-09

This is nuts, but not uncommon
 

J, it is smart that you are paying attention to the details! This finding may help you in the next level of appeals. BTW: have you got Laurie Todd's book yet? She's the Insurance Warrior...

Insurance Warrior
 

Thanks Harrison for the book tip. I do plan on getting it, but for now I am going to put the UHC issue out of my head and focus on being freaked out by the prospect of the CATHETER. I mean OUCH man. Should I be as spooked by the catheter as I am?

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L5S1 Herniation and Annular tear
Over 10 epidurals,
DDD, 2 discograms (positive),
Countless attempts at conservative therapy.
Surgery date 5-26-09

I know this is an older thread, and I hope things have worked out for you!

I'm just getting started with my research and would be very interested in the outcome of your apeal with UHC, was it successful? Any information would be appreciated?

Doing the same - keep this thread? CO?
 

Hey Jdouglas and Colorado2718, I'm going to stay with this thread for now, because I just dropped a note on your other thread, Colorado.

I'm going through the same thing, got the Insurance Warrior book(s) and forms: She's got the skinny on this appealing denials for XYZ as to form and approach. Super reference from Harrison above. It's worth the $30.00 online from her website.

I've only had one denial each from my WC carrier and UHC, my private carrier for the ADR. The WC wants me to do as the IME preaches; have my spine fused, but I refused and the Rush Surgeon is working with me for the Synthes ProdiscL since the Charite' is no longer supported/in service for new ADR's. I have the same conditions you guys do except I've not taken the epidurals because I prefer oral medications, i.e. Morphine, Tramadol, whatever works for tolerance. The shots have a high probability for negative effects on your nerves. You can research that and it's just masking your needed repair work. You probably know all this - sorry don't mean to preach here. It's nerve destruction and scaring, I think, which makes the steroids wreck future success with surgery. I'm not a medical Doc or an insurance knob. Just an opinion here from my reading.

I've had seven (7) surgeons (neuro/peds) examine me physically and/or my data (MRI/X-Ray) for recommendations for hybrid surgery. That's the welding job on the S1-L5 and ADR for L5-L4. I've been recently removed from the AxioMed Study; Their surgeons agreed that my damage was too extensive for single level ADR so I'm back in the real world with you guys and the fascist insurance criminals, looking for sympathy. NOT!

The reason I've had so many reviews is that most of these doctors don't pass my background checks due to loss of license, illicit drug use, or whatever their juicy records read. It's hard to find a qualified surgeon who's got a clean record, half a brain, yet alone happy patients.

I'll post here as developments occur with the appeals, denials, and whatever else gets thrown our way. Please do the same - Thanks! :look:

UHC Denial Review authentication - possible action.
 

My denial letter is signed by an MD who doesn't show up in background lists and the one who does is not related to/work/represent UHC. I suspect signature fraud here, but I'm going to fax request for further information because I need it/the confirmation that I tried.

Today, on the phone (with UHC) they would not provide any information about the denial authority signatory. I told them I was filing a grievance against their initial Notification of Denial and sought clarification for an authority background check on the signatory of the document. I don't think he's real because nobody can verify him or provide address or license reference.

I told UHC that I required this background check to vet their signatory's veracity for potential Class Action after their assumed future second review denial. This was only verbal today, but I am working on such since UHC is not honoring the FDA approval of TDR/ADR circa 7-14-06 (specific to ProDiscL) or earlier for the Charite' disc.

We are all being treated with obstruction and delay tactics from the same entity for the same condition and we all want the same solution; which UHC is denying against the law and facts. This smells like fun :nono:and Class Action would be provided should more of us fall into these similar Class Action requirements. I will be seeking such after/should I get a second denial from UHC. When that happens I will publically seek patient coordination.

My State (WI) Insurance Commission requires I play the internal (1st) and independent (2nd) grievance reviews before seeking contest in civil court.

I'm going to dot the i's here because I've petitioned huge companies in civil court, pro see, before, with satisfactory results. I want them for what they have turned medicine into in this fascist corporate prison. The cost of surgery is nothing compared to the time lost and nerve necrosis due to delays.

[Note: Same in other print; All parties open use permissible - RP.]

I'm just curious RP do you know if your plan is self funded or not? I read that a larger percentage of us (insured Americans) are through self funded plans then not. My Prodisc-C was approved by UHC on 1st appeal however I wondered if they approved due to my employer being the party paying the bill. Is it easier to get a cervical ADR approved then a lumbar? Good Luck.