external reviewer denied my 2 level ADR
 

Dear friends,

I am stinking mad. Friday I just got my external report that denied a 2 level ADR at C 4-5 and C 5-6. I live in CA but have Blue Cross/ Blue Shield of Ohio.
The report said I could get a fusion/ADR at level C 5-6 but not at C 4-5.

I have 2 MRI's, CT-scan, EMG/NG, and Discogram that all conclude that C5 and C8 and L5 nerve roots are blocked. They all state that I have cervical stenosis at C 4-5 and C 5-6.

The reviewer denied ANY treatment at C 4-5 based on the fact that I don't have stenosis at that level. The knucklehead also stated that just because something is FDA approved and your 6 spinal doctors say you need treatment doesn't mean you do.

Say what? The reviewer never examined me nor got a copy of any discs or images. How could he deny my medical testings findings? Was he on crack? Was he reading the wrong report?

What are my means of recourse if any? He sounds very incompetent. I am stinking mad and will keep fighting .:flaming: What can I do , if anything. Thanks for being so supportive.

You can appeal the decision. It isn't right that some bean counter somewhere gets to make decisions like this, but it is what it is. *sigh*

What do you expect from insurer?
 

Dear Running,

You have a right to be upset. However, what did you expect? The reviewer is paid by the insurance company to deny at least part, if not all, of your claim. It's kind of ironic from what I've read on these forums that the cost of 2 ADR's would probably be less than that of one fusion. You definitely should appeal the decision. Maybe you'll get somebody with some brains to actually review it.

In the worst case, perhaps you could have one level done and pay for the second level to be done at the same time "off-label". Since you're already covered for all costs associated with one level, you won't have to pay additional for hospitalization or surgical facility fees, anesthesia, etc to pay for the second level at the same time. It will probably be less than going to Europe for 2 levels.

Gene

Dear Gene,

Thanks for responding. I can't appeal anymore this is the end of the road.It was the external review that went out to a third party; MCMC.

This is what I expected ,since my doctors said I had positive neurological findings on C4-5 and C5-6; they ALL said that a fusion would definitely get approved. However, a fusion didn't get approved for C 4-5. The ractional was ; " Based on the medical information provided , treatment of the C5-6 level is medically appropriate (either with anterior cervical diskectomy and fusion or artificial disk replacement), as the EMG and MRI report show evidence fo C6 nerve root involvement. The studies do not support the need for treatment at either C4-5 or C6-7. Just because a product is FDA approved, does not mean it is medically necessary."

However, my BC/BS representative said all procedures have been denied. He said he will call for clarity.

I have three main nerve roots blocked. These results were found through complete positive EMG/NG studies; C6, C8 and T5 show evidence of nerve root involvement.

It's like MCMC from Quincy Mass said since your doctor and you were so greedy and asked for two levels( that have DDD and central canal stenosis that we choose to ignore the test results) now we will not allow surgical intervention! Yes, No surgical intervention at all!

They are saying in a sense that my Blue Cross Blue Shield doctors are incompetent. Forget about what your MRI's, Discograms, CT Scan's and EMG/NG show evidence of ; we are going to deny those findings even though we use them as diagnostic tools when we feel like it!

This is the other point I want to make Wellpoint's (BC/BS parent) profit was 355 million last year. Yes, their profit was 355 million. You mean you can't pay my surgeon or hosipital maybe 25,000 of the 100,000 fee that this surgery will cost? I have cogential cervical and lumbar stenosis. Why do I (we)have to fight tooth and nail to get treatment? I am a 44 year old woman. I am fit, thin and healthy the last thing I want to do is sign up for a MAJOR surgery. I want to be healthy!

Gene, please don't take offense, I am not directing this at you ; but at the state of our healthcare. I saw 12 , yes 12 doctors ! They all agree that surgical intervention is needed! Is B/C B/S saying that they are all incompetent ?:flaming:

Running, that's outrageous. I can't help but wonder if the reviewer was a podiatrist or dermatologist; anything but a neurologist. There was another poster on this site a few years ago that had this same issue. I don't recall her handle; but by the time she stopped posting she still didn't have a resolution.

If I understand correctly, BCBSOH approved one level and not the other, but then the external reviewer decided that you didn't need either? So now they want to relegate you to a life time of pain killers?

I wish I had some advice for you. In Texas we have a state insurance board to which these things can be appealed. Does California have such a process?

Good luck, Jeff

Jeff,

Even though I live in CA. My husbands corporate office is in Ohio. So since it's purchased there by the employer Ohio laws apply to us.

I am callied BC/BS today to ask them to reconsider. I sid they denied surgery saying i didn't have stenois , when it is clearly stated that i do on all medical testing . What was this examiner smoking? They told me to show the external denial letter to my surgeon and see if he'll write a letter in response to the denial. My surgeons. all have said their exhausted fighting insurance companies for basic procedures. I'm not sure they will write another letter.

Why are they making me and my doctors jump through hoops? I'll see what the office says tomorrow. I put in a call to them today.

My pain is bad enough...now I'm in insurance hell, too! :flaming:

Condolences. Please keep us posted; especially if you end up killing someone.

That's outrageous.

Nothing final until heard in a court of law
 

Running, Nothing is final until a judge in a court of law makes a decision. Just because the insurance appeals process is over doesn't mean that this process is. In fact I see it as just the beginning. I suggest you get an attorney involved (probably one who specializes in personal injury or malpractice would be best). If the attorney writes a certified letter, stressing all the points and opinions of 12 doctors of why you should have surgery, it's likely to reach someone at a different level of BCBS who most likely has a brain. Believe me, the insurance company does not want to get involved in litigation. They would have to hire their own attorney or take time away from one of their in-house counsel members. The burden of proof now shifts to them. They are the ones who must prove that you won't benefit from any surgery. Good luck to them with everything you have to show otherwise.

Yes, you are going to probably have to pay a few thousand dollars to an attorney. However, if it gets your surgery ultimately covered by BCBS, it's money well spent. It's also far less than you would spend traveling to Europe to have it done there. IMO, I don't think this is going to get further than a certified letter from an attorney. Once they see they you have one involved, they are likely to back off. They know that if anything ends up wrong with you because they refused to pay for the procedure, they are in for a very big lawsuit. Nobody wants that.

Time to contact an attorney. Please keep me posted.

Gene

Thanks Gene, my father said the same thing . However, my only problem with that is that people on this forum have said don't bother it won't help . Do you know many or anyone who has had luck getting a lawyer?

Has anyone reading this had luck retaining a lawyer getting their denial overturned?

Tammi

Regarding legal counsel
 

Tammi,

This is one thing I would not rely on the board for. You have nothing to lose (except maybe a few thousand dollars) and everything to gain. You have exhausted the appeal process. Now the next step is to retain an attorney. I'm sure you can see most personal injury/malpractice ones for little to no consultation fee. In fact you can probably do a telephone consultation. At least you will know what you're up against. Who knows, maybe you will be the first person to overturn an insurance claim for this purpose and you will be setting a precedent.

If you want send me a PM with your contact information. I have some friends who are attorneys back East. While they might not have jurisdiction in CA or Ohio, they might have some helpful things to say.

One other avenue that you can try is contacting the media. Most NYC area stations have some consumer advocate who helps people with everyday problems (on WPIX, we have "Help Me Howard"; on ABC, we have "7 on Your Side"). I've seen similar stories to yours involving HMO's not wanting to cover a procedure. Usually once the media goes public with it, the insurance company quickly changes their mind because they know they're being viewed like a microscope. If you don't mind going public, this may be a good route to take. I would e-mail the station as much info as possible (copies of all medical reports, doctor's opinions, insurance statements, etc). The more the station has, the more likely they will televise your situation. If they choose to televise your story, action on the part of the insurance company is likely to be swift.

One final approach which is not as quick is to contact your local Congressman (both U.S. Senator and member of the House). Also send a letter to the editor to your local newspaper. The more publicity you get, the more likely the insurance co. is going to get wind of it. Last but not least, send a letter to the insurance commissioner of the state that's involved (I'm not sure if it's CA or Ohio). Each state has a regulatory authority that reviews insurance companies for claims they don't pay out. This is probably used more often by doctors than patients. However, they are there to serve all. They may even have an online complaint form to fill out and submit.

In summary, going through an attorney may be the best way to go. A good one may take some of the steps I suggested in the last 2 paragraphs. However, if you want to save money upfront, you can try some of the things I suggested there on your own first. Please keep me informed.

Gene