Well, I sent the flunkies at Empire Blue Cross Blue Shield my first level appeal today. All 97 pages of it! They wanted documentation and I gave it to them. Everything from peer reviews to a paper I found showing 7-11 year follow up results for those who had ADR surgery. I already know that they will deny it. I was told that by the nurse there handling my appeal when I called to find out the appeals process. I was nice, I didn't tell her where she could stick the denial. http://adrsupport.org/groupee_common...s/icon_eek.gif

Hopefully I'll be hearing something in about 17 calendar days which includes the time it takes the package to get to Albany. My employer & their insurance broker are helping me to fight BC/BS to get them to pay for the surgery. I'm keeping all fingers & toes crossed that they will rule in my favor! I'll be in touch!

Good luck Karin! Just seeing the words Blue Cross gets my blood boiling...

Justin

wasn't Empire one of the few BCBS that had been covering ADR???? am I confusing it with another BCBS? Are you trying to get a one level Charite or ProDisc??

i'm having trouble bringing up the list on my computer but look at:
http://www.charitedisc.com/charitedev/domestic/patients...r2/docs/coverage.pdf

in fact i did a search with empire and thought ANS was given preauth from Empire in NY???

sorry...i see you've already talked to allan before...so did Empire change their position or was Allan just an exception? if you don't mind...i'd be curious to hear what's happened with Empire on the ins issue

Hi Justin,
I know what you mean. A nurse at BC/BS called me today to say that they received what I call my "manifesto". She gave me the "we'll give this to our second level medical manager to review". I wanted to say just approve it but bit my tongue. It's so hard to behave! Hopefully in 15 days I'll have a positive decision. http://adrsupport.org/groupee_common...n_rolleyes.gif

[QUOTE]Originally posted by LBP:
wasn't Empire one of the few BCBS that had been covering ADR???? am I confusing it with another BCBS? Are you trying to get a one level Charite or ProDisc??

Sorry it took so long to get back to you. I had to study for a test in Human Biology & I crashed before I could get on the computer to respond. I am trying to get a 1 level Charite at L5-S1. Some Empire Blue Cross plans will pay for this surgery & most will not. I know that Horizon BC/BS of New Jersey released a statement that they will pay for it. However, Empire BC/BS of New York will not cover it. I tried to get pre-certified thru BC/BS & they gave me the "it's experimental" fluff.

In my research, I came across a notice from Aetna which states that ADR surgery is deemed medically necessary & it would be covered under their plan. The catch is, the decision to cover this procedure is up to each individual plan. In other words, 1 Aetna plan would pay for it whereas another Aetna plan would not. Another interesting tidbit was that any of these plans could reverse their decision at any time. Say if Plan A covered it as of January 1, 2006, they could then decide that as of November 1, 2006 that they would no longer cover the procedure.

It is my understanding that Empire BC/BS has covered 1 ADR surgery in New York based upon individual consideration. I would love to know what type of documentation this person had in order to get the approval. I'm hoping that what I sent them will be enough to open their eyes & rule in my favor.

Well good luck Karin. If it's not approved will you consider tyring to get into the Kineflex/charite trial?

My ins recently changed and I am trying to figure out the best timing to use up my claims. I figure I get one shot with Charite and one with ProDisc but I am not even sure about that. My last ins said I was entitled to a whole new appeal process with each new manuf disc...but really I'd like to have the FDA approve 2 levels before I use up another appeal. so here I sit and wait and watching to see if any other companies start changing their policies.

Again, good luck!

So I received a decision today regarding my 1st Level Appeal. DENIED! Their reasoning, that ADR is investigational/experimental. Gee, how original! That's ok. I'm gearing up for my 2nd level appeal. We'll see if I can bury them under more paperwork! http://adrsupport.org/groupee_common...on_biggrin.gif