Hi Everyone!

Just thought I would drop in since I’ve been gone for five months. Life just got a little out of control with school and my grandmother was diagnosed with terminal cancer in late May. I made the trip to Germany with my mom to see her one last time. My grandfather answered our prayers and took her home to be with him in early September. http://adrsupport.org/groupee_common...icon_frown.gif

I was suppose to have the Charite ADR surgery on July 12th but canceled it due to my trip to Germany. I also found out three days before I left that Empire BC/BS of NY still considers this surgery to be experimental and they won’t pay for it. Glad I found that out BEFORE the surgery! http://adrsupport.org/groupee_common...s/icon_eek.gif

I have been fighting with my OS’s secretary to get off her duff and send a letter of medical necessity to BC/BS so that I can get my denial letter and begin the appeals process. I have been trying to light a fire under her tush since April. Still, she hasn’t done it. Her words were “well it takes me hours to create this letter and it’s just a waste of money because they will just deny it anyway”. http://adrsupport.org/groupee_common...s/icon_mad.gif Well this past Thursday at 3am when I could barely walk, I typed up a nice yet demanding letter to my OS & e-mailed it to him. I also faxed a copy of the letter to his office Thursday afternoon and within 30 minutes, his secretary called me & apologized up & down for being negligent & putting me thru all of this stress. Hopefully she got this letter done today.

I spoke to my employer about my situation a few weeks ago. Her mother has had 2 fusions done so she has an idea what I am going thru. This woman turned around and said to me, “you let me know what I can do to help you”. I was absolutely speechless! Seems she has the gift of gab and the company has a very large contract with BC/BS. Hopefully we can get a positive result out of this.

Well, the hydrocodone & tizanidine are kicking in. Think I’ll call it an early night! Thanks for listening!

Karin,

It is good to see you here again! I am sorry to hear about your grandmother. Good luck with everything--keep us posted, as we do care.

Justin

Hi Karin,

I too have Empire BC/BS of NY. The authorized a one-level three years ago but I was told by Dr. Regan's surgery scheduler that no way will they pay. Also the same was confirmed by a fellow who knows some ins/out of the insurance industry whose wife was trying to have an ADR with them.

I wish you luck in fighting them as I may have to also. If I find anything, I'll PM you.

Good luck, Allan

Justin,
Thank you for your kind words. I hope to be able to surf the boards and post more often here.

Allan,
I'm sorry to hear that you are in the same boat as I am with BC/BS. It took a lot for me to not yell at them on Friday asking where the heck they got off calling this surgery experimental.

My OS says that they are in breach of their contract by denying me medical coverage for this procedure but how can you fight a big insurance company like that? http://adrsupport.org/groupee_common...n_confused.gif

If I can find out anything that will help you, I'll PM you as well. Thank you and good luck to you as well.

"My OS says that they are in breach of their contract by denying me medical coverage for this procedure"..

Hmm, wonder if there's a legal precedent set for 'em to uncover.

You be well and thanks. - Allan

well blue crap has a double standard as if you are insured though fed insurance they have to pay for a fda approved device. but if you are private insured
the rules change. there has to be something that should be done there. if we cant rely on the fda then why do we even have one? meaning FDA
chuck

Karin, ditto on the "welcome backs!" Pun intended, hope we can help...

http://adrsupport.org/groupee_common...icon_smile.gif

Well, from what I understand, my OS's secretary was told that it was in BC/BS's contract that they do not cover experimental/investigational procedures. My question is, who are they to determine what is experimental/investigational? As for any legal precedent, I couldn't tell you if there is any at this point. I am studying to become a paralegal and unfortunately I'm not taking any legal classes this semester so I am not able to log into Westlaw to find out that information.

My OS said there really isn't any money in it for an attorney to fight an insurance company about that and it would be difficult to find an attorney willing to spend the time and money on fighting it.

His secretary suggested that I write to my congress person to ask for help in my appeal which is something that couldn't hurt to try. I've been working all night so far looking for peer reviews and information to submit for my appeal.

Harrison,
Thank you and it is great to be "back" with everyone! http://adrsupport.org/groupee_common.../icon_wink.gif