First Appeal Denied
 

I talked to my spine clinic last Thursday prompting her to call Aetna and check on the appeal status: Denied for the same reason experimental/investigational.

On to round two...

Kelly,

Here's the synopsis of my four rounds with BCBS-TX.

- Submitted claim
- BCBS - denied as not medically necessary
- Submitted appeal showing medical necessity
- BCBS - denied as investigational
- Submitted appeal showing almost 1000 years of clinical data
- BCBS - denied stating that approval was against company policy
- My employer objected to the absurdity of "company policy"
- BCBS - denied stating that the contract allowed them to deny if I went out of US

Thanks for the update and keep on them. Insurance companies seem to be drifting away from the trend of "deny for any reason", as demonstrated in my case by BCBS-TX.

Good luck, Jeff

Thanks Jeff, and sorry you had to paddle up the same creek :insane: I'll be patiently pressing on in hopes that I clear a path for those behind me :) As well as saving myself thousands $$$

Continue
 

BCBS is the only game in town, well except yours, so we really don't have any choice, this is the game they play.

If they would just admit their is a better alternative, and quit paying for all these conservative measures, and eating up our allotments, then people would be more productive and there would be a better return on investment.

The insurance Companies are always, and have been, involved with politicians, this is the biggest, single obstacle to good health care and insurance.

There are only two options, an ADR or run the risk of more damage, and get by with pain drugs.

:insane:

Surgeon appeals second time
 

My spine clinic emailed me today to say that my surgeon worked with LDR (mobi-c manufacturer) , signed and sent the second appeal off via fax to Aetna today. She sent me a copy. If anyone would like to see it PM me with your email and I'll forward. If it gets approved ill post it in the approved appeals thread. I am anticipating that it won't, however. :sulkoff:

Second appeal sent by surgeon DENIED
 

Errrr. :raspberry: Not that I expected any different. My surgeon's second appeal has been denied. I am admittedly, for the first time in this process, very bummed about this. But, that is what insurance companies count on, that you will give up.

I feel fortunate for so many reasons. Mostly that I am not in too much pain and that I can wait for surgery and continue fighting for insurance coverage.

I've already been working on my last and largest appeal, the one that will be sent by me, in anticipation that I will have to fight this till every last option is exhausted. Thanks to this forum, Laurie Todd's book, a few kind people who shared their appeals and my ever persistent researching self, I should have a good case prepared by the end of the week. LDR has also kindly stepped in, and will send an appeal on my behalf. Although this is tempting, I've decided to include their information in my appeal, but not use theirs as my sole defense. When I read the one prepared for my surgeon by them, it was very well thought out and put together, with all the medical jargon and statistics etc that I never could've put together on my own, but it is very mobi-c specific, which leaves out all other important case studies, clinical trials, law suits etc that collectively could have a greater impact for my rebuttal. Although I am seeking a two level with mobi-c I think it's better to include everything.

For those of you who wrote your own appeals, did you bind it? Did you send it to higher up's than the appeal department at your insurance co? Did you fax it or send it certified mail? Any other info would be helpful. :)

Best of luck Kelly.

Ranting and venting
 

I am so frustrated. Nothing has changed other than I received a copy of the denial in writing today. They state the denial is based on the FDA has not approved a cervical two level. AND THE FDA HAS APPROVED A TWO LEVEL. Do they think they can just lie? Do they think I don't know that the FDA has approved? Did they not read the appeal paperwork that includes the FDA approval???? I feel like this is nothing more than a delay tactic and I AM IN PAIN AND IMPATIENT. I am trying not to take it personal,but just for today, I'm letting it be personal and I am mad! On the other hand, now I can have an external review. I hope that whomever looks over my last chance appeal realizes just because the insurance co says something, doesn't mean its true. .;$!!@%#£>?!!:raspberry: thanks for listening. Had to get that out. I feel better.

External Appeal
 

My third and final round of appeal is being sent in the morning. I'm very thankful that I had so much help from My Dr. And his staff, as well as Gail at MCRA who finalized my appeal paperwork, including letters and chart notes from my Drs, the documents prepared by me personally and her 81 page packet of support documents. Any prayer warriors out there, feel free to offer some words up for me.

I'll post the results of the determination when I receive it, of course!

Drum roll please......

Hope for the best,
 

The insurance industry is on it's last leg, if the ACA is not repealed in 2015, then it is curtains, they will not tell you the real reason, this is so they can have two levels of insurance, really it will be Public insurance, and then those that can afford the care out of pocket.

IOW, they have destroyed the insurance industry.

I decided to have this done, I will pay, hope for reimbursement.

Hope your appeal goes well.

You might have a chance, the Mobi-C was approved in the USA, keep at it, the insurance needs to learn, and I hope the Congress gets a real wake up call this year, 2014. The FDA is one of those regulatory agencies that should be abolished.

Other info, at a post earlier, back in April, I said 'their' and should have said 'there' is a better alternative, slip on my part.