Hi, all.

Okay, the next and final step is an Independent Medical Review. There has not been a case where UHC or Pacificare for that matter has approved an artificial disc replacement to date. But, why not me????? Why can't I be the first????? Someone has to be, right?

How long does it take for an Independent Review? I realize that it varies, but can anyone give me an idea? I'm dieing here.

blue crap told like 2 weeks
chuck

I believe Chuck is referring to Blue Cross Blue Shield, also known as Blue Corpse Blue Sled.

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

Yeah, that's what I figured, Harrison. http://adrsupport.org/groupee_common.../icon_razz.gif

So, Chuck, in reading your signature line, you are still waiting for SOMETHING??? http://adrsupport.org/groupee_common...s/icon_eek.gif

I read somewhere by law they have 30 days to do the review in but dont hold your breath it will be in your hands in 30 days mine would do the review and date it the day before the 30 days was up or on the 30 day mark then took about 10 days to get it out to me.
I had Great West then but have UHC now. Hope this helps

go*big*red
i leaving tomorrow sunday to guilford ct to see dr james yue. to see if i can get into the fda clinial trials comparing prodisc to activ-l adr. if im not a candidate ill be asking for a referal to pro-spine
i have my lastest films on cd both ct scan and mri no concast.cd is cool all the nurses told me they don't do that but later talked to someone else and said it was no problem and it was free. also includes all the reports. just put cd in a pc and has the 3d viewer all on the disc.i have been waiting and fighting with insurance company for well over 2 yrs enough im getting fixed this yr 2006. so hopefully im still good to go i was offered the prodisc study by dr balderston at pa hosp a yr ago so i hope i still am. i really rather not have to borrow the money in case i end up in that 10% that doesnt do well.
best wishes
chuck

go*big*red
also watch the appeal process but your reply time for appeals gets shorter after each appeal the second appeal with blue crap i only 2 weeks to get the last one started. they really r pricks {insurance companys} and what really kills me is the ceo of blue crap here made 27 million last yr. and this yr there asking for a 30% increase in premiums. and they dont want to pay for any thing. i had letters written by professions. and in my mind all apeals were denied before they hit anyones desk. i also sent about 50 pounds of info comparring adr to fusion to not advil.hopefully this isnt the case for you http://adrsupport.org/groupee_common...icon_smile.gif
wishing you the best of luck with our appeals one thing in your favor is more time has passed.
chuck

Good luck with that. I had no luck with UHC. The whole process is a scam. The get to pick the doctors etc. It is a total crock. They pay these retired fossils to do the reviews so you know where they are going to side on. My first appeal doc was a retired arthritis doctor. I have heard also that they use a diabetes specialist. From the time I have spent on this forum I have noticed UHC being the worse. That being said someone has to be the first so I hope you are it. Good luck.

Hi all,
I haven't posted in awhile. I am working on my first appeal letter to UHC right now. My denial letter was signed by a medical director whose specialty was geriatric/elder care. That's helpful...not.
And yes, someone has to be first, so no giving up!
Andrea

I agree with the 2 above my first appeal was reviewed by an OB/GYN, the second time supposedly by an orthoapedic surgeon. His suggestions were so ludicrous that I questioned it. I got through to find out who he was and ROFL he was a local doc here so I called his office and asked them about him. I found out he was a sports med dr and worked on elbows, shoulders and knees, had not done any spine surgery for 12 years since he was in the military. U can bet I brought this up in my final appeal. Same thing happened again sigh. Its so great they call it an independant medical review but they get to choose the company and of course the ins pays for the consultation so which side do you think the doc is going to decide on and how long would he be employed in such endeavors if he disagrees with the ins company and they have to approve procedures that they dont want to?
Oh and get this, the ins company rep told me that they dont even specify who the doc is when they send a case to the medical review company they leave it up to that company to find someone who is qualified.
Oh the wonderful things u can find out when you delve into the workings of the lovely insurance folks.
I wish you much luck and much more luck than I had during the process.
I had Great West and now I have UHC and from what I have seen so far yeah you can do worse Great West is by far the worst ins I have ever dealt with in all my years. That includes 25 years background in the medical field and even did some insurance billing for a few years a while back.

So, how do you find out who has reviewed your case dr. wise?

And, what were the denials based on? What UHC has said is that it's still experimental!!!!! So, Charite' people sent a packet to accompany the rest of the stuff to the "independent" review.

There is no question that I need surgery. And, they are more than willing to approve a fusion. Grrrrrrrrrr. I'm almost at the point of buying more time with a second fusion at L4/5 and then in a year or 2 (when the pain becomes unbearable at L3/4) do an ADR at that level. Shouldn't have too much trouble then getting it approved.

That is if this is denied. My other option is perhaps going to the insurance commissioner of Colorado. I have dealt with them with one of our employees vs our group health insurance and the employee won. It was actual payment of claim, though and not preauth. But, that might also be worth a try.

But, I don't like the way my thoughts are running. I want approved. Plain an simple.

Thanks for all the replys. I'll keep you posted. I like the idea of being the first of many.

I called them and requested the information as to the DRs credentials who reviewed my case as it was necessary for me to have that info for my next appeal http://adrsupport.org/groupee_common...icon_smile.gif
They are required to send you by law all of the documents that they use for your review and all the info that you sent them etc. U have to request the records in writing but I got the info on the drs over the phone by the case manager of my appeal.
They didnt like it one bit either and one nurse was a witch and she got reported for it but that is a story for another day.
Call and ask them for the info and ask them for the papers that they used to deny your appeal. You might find it very interesting to see what it says. I got the whole report from the dr etc.
Kim

I requested the medical director's curriculum vitae and his credentials in my letter to UHC requesting the docs but conveniently they didn't include anything re the dr.

workers comp here in delaware used to be able to call their exams of claimants IME's(indep. medical exams) However, if they write that in letter to claimant or accidently call it that during hearing they can be fined $500. In our statute. Must be called DME now(Defense Medical Exam). No such thing as Independent with worker's comp.

Just my two cents. But in case of healthcare, its possilbe to be independent if your doc and the BCBS doc picked who was doing the review, otherwise, same scenario as comp and its far from independent at all!!!

Sorry, doens't have much to do with topic, but thought might find interesting.

take care, bill

Hi Bill, Independent Medical Exam misnomer is one of the topics I missed in my presentation preparation to CT Labor Committee for tomorrow at the State Capitol. I am bringing your information verbatim to the committee co-chairs. These are the Senators who over see WC here. I have whined and protested my way to the top. I am planning to request a Senatorial Review and Investigation into WC tomorrow. The traditional IME lie and our Voluntary Agreement form, (which states This is not a Final Settlement, which it really is) have to go. So you see, you may not have thought it had something to do with the topic, but it is going to the top tomorrow. Posting Pays. (JL)

As I posted in another thread, I'm going for my 2nd Independant Medical Exam on Tuesday. This guy is NOT a fossil. He has done a handful of Charite's so I may be seeing the right guy. I'm going to pick his brain about his decision to use Charite and hopefully get him to refer me to a good disc doctor. Liberty Mutual's In-Network WC doctors have very little experience in ADR so I may wind up in court anyway.
I pushed my appointment with Hallett Mathews(East Coast Maverick doc)back until May hoping I'll get approved by then.
James Yue would be a great plan B for me AND for the insurance co. since it may save them some $$$.

For my IMExam, I'm staying in the historic area of Phily which is just a few blocks from the doctor. Me & Sweety are celebrating 1 year and we're taking a mini-vacation (Atlantic City first, then Phily) so it won't be all doctor stuff.

Okay - update.

Spoke with CA Ins. Commissioner's office yesterday.

1) they have to determine jurisdiction.
a. If Pacificare is a trust, then California does not have jurisdiction and I would need to go through Colorado.

2) Pacificare IS NOT a trust, so CA does have jurisdiction.

3) Prove to them that the Charite' is not experimental. That is the reason that PC gave for not approving.
a. I now have a call in to the DuPuy people to get national publicated articles with trial results, etc.

Interesting note: no one is arguing the fact that I need surgery. This guy said that if it were still experimental, that no one would have approved it. I thought, where the )*()& have you been? They've been approving it all over the states.

At the time that we do all of the above, then they send the info and my file to an independent medical examiner. Then, he gives his determination. I asked if they send my file to a pediatrician or what. He said they contract with a group of drs., spine specialists included (dinosaurs?). So....we will see.

Okay, new news

Because it is not a trust, correction - it will be the jurisdiction of Colorado, not California. That has it's benefits, and drawbacks.

Just waiting to see. Really tired of this! Is that their ploy? To wear us down?

When Liberty Mutual Workers Comp said I needed an Independant Medical Exam, they gave me a choice of three doctors available in my area. I quickly called all three and found out which ones were "disc friendly" and went to the one with the most experience in ADR. One doctor was totally against ADR so I stayed far away from him.

If you are asked for an IME, ask for a choice of different doctors. You can find out within minutes if they are disc friendly or not.

Eddie, I think there is some confusion between what is an Independent Medical REVIEW vs and Independent Medical EXAM (IME).

Go Big Red, I have PacifiCare and was denied all appeals. I applied to the Ca Dept of Insurance for an Independent Medical Review of my case. I used to live in CA before moving out of state. I was a resident out of state when I requested my Indep Medical Review. I called first to make sure I shouldn't be filing with my own state's Independent Medical Review. Since PacifiCare is based out of CA they told me I was filing it in the right place??? Have you called both your state in addition to the state of CA to make sure you are requesting the review in the right place?

I'd love to hear why (specifically) they told you to file in CO. Is it because of the acquistion by UHC? I still haven't received any notice from PacifiCare that anything has changed for me.

The CA Dept of Ins, sent it out to a 3rd party company and they had 3 MD's review my file. I demand that orthopedic surgeons review my file. They only provided a resume of experience but no names. I was only able to get the names of the MD's PacifiCare used to deny my claim. NOne of them were orthopedic surgeons.

I see that now. Good luck. I'll let you know what Liberty Mutual says so maybe you can reference some of their findings for your case.

The process certainly can be trying and the extended timelines benefit the insurers. Stay vigilant and continue to make phone calls and ask questions. In the meantime, massage and lymphatic drainage may help reduce some of your unpleasant side effects.

First of all, LBP - Colorado Insurance Division has jurisdiction over this because we purchased the policy in Colorado, from a Colorado agent and we are located in Colorado. I have, since I first posted this, got Colorado Insurance Commissioner involved. They have been very gracious and have tried to contact PC 4-5 separate times by phone giving them ample time to answer some questions over the phone with no response! So, as of today they are lodging a formal complaint with an inquiry. I'll have a copy of the letter by the end of the week.

I think that #1, PC always says to contact State of California because that's where they are based and are banking on people not inquiring further with their own Division of Insurance. #2, That they (we) will get tired and just plain give up. (I gotta tell you I was almost there!)

If you purchased your policy in CA, then maybe that's why it stayed there?

Also, Crystal - I am doing massage therapy - have for gosh, about 6 years. I don't think I'd be standing if I didn't have that. Just had my bi-weekly massage this morning.

I've been in so much pain, the nerve block has worn off for the most part - I've got a call into my surgeon to see if we couldn't go ahead and schedule the surgery for the 2nd week in July as my policy is up for renewal in August and I would have to meet my $3K deductible again. That's the other thing I think they are counting on and that is getting into a new policy period. This way, if I am approved, I'm on the schedule. If I'm not (I'm not even going to go there!) then we can cancel. Don't know if they're willing to do this, but I'm gonna ask anyway!

*sigh* - all this red tape!

For you UHC guys, I talked to the insurance Manager at my doctor's and she said that she has gotten UHC to pay for ADR recently. As long as the policy is based somewhere other than NYC then you have a chance. I'll ask her about it the next time we talk. Keep chugging along big red!

texas-t why is nyc singled out any idea.
im scatching my head on that one.
chuck

I have no idea, but will ask. I suspect that UHC NY is a seperate business entity in some form.... but it makes no sense that one part of a company would pay for ADR while the other arm does not. The more I learn about insurance the more upset I get.... it's crazy.

Does the state have any effect on policy coverage? I think I read somewhere else on the board of individuals having issues with insurance based in NY.... just a thought

Well, if you will note, my name has changed as I couldn't get logged in under my old name. So, no astricks.

ANYWAY - just to update everyone, finally got the Independent Medical Review request off to TX, not CA (TX is just where they process) and now CO is handling my case. PC or UHC or whoever the heck is making the decision on the REST of my life has 30 days to respond on decision. They must have received it sometime last week I'd say Thurs or Fri. So, 1 week down, 3 to go.

In the meantime, I've packed on weight, been depressed and in more pain and now both legs hurt, not just one. I'm going to have bariatric surgery prior to my ADR if they wait much longer! Nothing to kid about, I know and I'm not kidding.

Well, huh! Look at that, my astricks are back, but I've only posted 3??? Oh, well, no biggie. At least I'm back

Okay - so an update.... I received a letter from Pacificare today stating the date and time of my phone interview - Wed, June 7 at 1:00 MST.

Has anyone here done this before with their health insurance company? This interview? What am I to expect. I want my surgeon (my designated representative) to be with me on the phone with them. They said in the letter that I could have him there.

I'm a bit nervous. This is it. Again, what am I to expect? Are they going to rake me over the coals? What???

I'm now dealing with occassional bowel incontinence. Sorry, but it's a fact. I imagine that it is just part of it, right? The whole thing just sucks if you ask me!

Good luck on your phone interview! Two thoughts: tape the conversation (I'm sure your insurance company will be taping it as well) and be sure to get the name and credentials of the person on the other end. Is this really suppposed to be an "independent medical review?"--IME's are a farce anyway but medical exam by telephone?! As a provider, it is usually not a good sign when an insurance company asks me to do a phone review--they're usually going through the motions before they deny benefits. I hope this is different for you.

Me, too. But, I do have the opportunity to do it in person, but I'd have to fly to Texas and I'm sure my surgeon wouldn't do that. And, I don't want to do this alone!

Thank you!

This is a good topic with some real informative posts. I have learned alot that may be useful in the near future. Oddly enough, my first ADR in Feb 2004 went through with no problem - fully covered. I still haven't figured that one out, but I believe it was in part because at that time there was no code for ADR. But anyhow, since then Health America Insurance has been denying coverage for everything they possibly can for me and taking their good old time with every step. So, If I end up needing the additional 2 level ADR, I am sure it is a hopeless battle with this insurance company especially, or any other, most likely.

They rejected my surgeon's pre auth request for the Nucleoplasty procedure that I am having on Thursday. When we appealed it, they said they had 4 weeks to decide, but that it usually only took 2. Well, my doctor had to call them after 6 weeks and they claimed it had been reviewed, just not decided on. I thought we had a good and informative argument too. An hour later they called to say it had been denied. I would love to see these documents you talk about, as I don't think anyone looked at it before that day when it was denied. I don't think mine was supposed to be an Independent Review though. ?? I think it just went in front of their medical review board. I am not sure. I need to learn more about this, that is for sure!!!

Good luck to you Big Red. It sounds like you really know alot about these insurance processes. Are you in the medical or insurance field yourself?? Or self taught for survival?

I have a question - off topic - both Eddie and Chuck mentioned the trial with Dr. Yue and saving $$$. May I ask why? Is some or all of the costs of this trial covered?? Just curious. I have considered seeing Dr. Yue before I take the big step and go to Germany (my next step if this nucleoplasty doesn't work). I imagine I wouldn't be a candidate for Yue's trial or any other trial though.

Well, good luck to all.

Go Big Red,
I wish I had some good advice for you. I think of you often and feel it's a shame that you are still dealing with this. I am quite sure your surgeon (and mine) will be very competent in the phone interview, as will you. If you feel the need to vent, let me know. Meanwhile, keep plugging away.

Hi, Mars

Nicole called me yesterday and Dr. P is in surgery all day that day and 1:00 is right in the middle of a big one. When she told me that, I just lost it. I can't believe how emotional I am! But, when he gets back into town today she's going to speak to him about it anyway. And, the rep for Charite' has done this many a time and is willing to phone interview with me or even go in person.

So, I'm going to check today and see if the interview is in Denver. If it is, then off I go in person. It's just so scarey. I hate my life being held in the balance by a dr. I don't even know and doesn't know me.

You know, we deal with the pain and crap for so long that looking at us it's hard to believe we are in constant pain, you know?

Anyway - may give you a call. Thanks. How is your recovery going? Like the surgery and injury never happened, I hope.

Well, so the saga continues. It wouldn't matter if Dr. P. was available at that time or not as they do not allow the doctors in on the call. So, the Charte' rep was going to sit in, but they won't allow that either. *Sigh, sigh*

So, that means that I'm on my own. The rep told me to not be intimidated which happens, maybe not intentially (yeah, right) but it happens often. Oh, and get this. Nicole and I had decided to by-pass the internal review and go for the external independent review instead. PC disregarded that request which was clearly stated in the letter that we could choose either. So, in total disregard to my wishes using THEIR protocol, this is an internal review. Which means, to my understanding, that there will be YET AGAIN a bunch of suits deciding on MY life.

How can they do that? They don't even know me! They don't know what my life is like. They don't know anything nor do they care~~~~~

I am sorry but not surprised that you are having to go through this. You are in an adversarial situation.
A couple of additional thoughts:
(1) check to see if Colorado statutes allow you to file a complaint to the Medical Board against a physician who does an "independent medical exam/review." Unfortunately for me, Arizona law does not permit this, which means that physicians here who do IME's can lie, commit perjury, prostitute themselves for insurance companies and yet are totally untouchable.
(2)There is a certification board for IME doctors which has a code of ethics to which they must subscribe. When asking this doc for his credentials, also inquire whether he is certified by this board.

Wishing you all the best.