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-   -   Appealed and denied (https://www.adrsupport.org/forums/showthread.php?t=5512)

10-25-2005 01:21 AM

I received my denial letter to my appeal with my carrier (HealthNet) the other day, and thought it might be worth posting their reasoning for the denial to see what people have heard/seen in that regard.

I appealed and provided significant backup, detail and even a HealthNet peer-to-peer review from another patient with the same condition who was approved for ADR. The HealthNet reviewer cited the FDA approval and the fact that the FDA approved with the condition that the Charite manufacturer conduct a five year investigational study on the after-surgery effects and outcomes of the device. Note the term "investigational," which they basically used to explain everything away. If the FDA requires a five-year investigation, the device is therefore investigational, they claim.

It's amazing to me the lack of consistency not only in the industry, but within one insurance carrier. In reference to the other patient who was approved, they stated that was not relevant, as their policy clearly states that appeals and decisions are on a case-by-case basis.

Thoughts?

Thx

gh

letteski 10-25-2005 02:41 AM

My insurance "Health Comp" said they would not consider anything on a case-by-case bases and in the end paid in full for the ProDisc non-FDA approved device after saying they wouldn't.

There is no rime or reason to the American insurance companies. Do you have the right to another appeal? My heart goes out to you.

Paul 10-25-2005 12:32 PM

My denial used the same line from the FDA approval. The easy out for the insuarnce is who is to say when there is enough evidence that this is safe and effective. The insurance company holds all the cards in that they can say this for years to come. There is no cut off point. If there are 20 journal articles out there they will say not enough when 25 show up ..not enough. Same for years. They are the ones that say hasn't been enough years. Quite ironinc how they want to be able to use science to show this is safe and effective but totally ignore the science of statistics by not having any endpoints as to say ahh, that is enough data.

Frankly, I don't know how nay of them sleep or night or can look themselves in the mirror.

go*big*red 10-25-2005 01:27 PM

What blows me away is that they'll approve a fusion which is almost guaranteed another surgery in the future due to added stress. My first request was denied and if the appeals process does not go my way, I'm gonna call them and give them a piece of my mind. I know they'd approve a fusion.

Let any one of them live with our backs for a week and hear them sing a different tune! I'm sorry, Greg AND Paul.

Paul, are you done then or in the appeals process? And Greg, can you appeal again? Have you tried calling them and talking to your adjuster personally? Sometimes that does help when they have a voice instead of just a name.

bmills 10-25-2005 01:46 PM

CIGNA turned mine down all the way through.

Being in the Kineflex/Charite study, the insurance company must first be billed to see if they will pay.

They are denying the bills from the surgery just as expected. Just like they denied all requests for approval and all appeals before I got into the study.

Yes, it is obvious that the insurance companies are in complete control. They keep it open ended. Some could choose to wait for 5 or 10 more years of US data.

The tide may be changing on them as the public becomes more aware of ADR options but it's not there enough yet.

Has anyone heard if Medicare has come out with their official stand on ADR? It was expected to come this month.

Brady

Paul 10-25-2005 03:23 PM

Big Red,

I was denied on my first appeal. I decided to not fight anymore and have scheduled a fusion for Dec. 6th. My doctor feels that it is going to be at least another year before insurance starts paying for 2 levels. And he has no special insight just a educated guess on his part. My insurance for next year is suppossed to go to an 80/20 type deal and if that rumor is true (I have no reason not to believe it as every year I have worked where I work it has gotten worse and worse), I will not be able to afford either surgery. So I pretty much have given up the fight.

See my post on my denial. i just noticed I titled it second appeal but it was my first.

http://www.adrsupport.org/private-cgi-bin/ultimatebb.cg...t_topic;f=3;t=000563

luvmysibe 10-25-2005 04:31 PM

Greg,
Welcome the forum! Have you used the appeals guidebook for suggestions and ideas? If not, please request it from DePuy Spine. I used the materials to assist me when I appealed my case to the CA State Workers' Compensation Board. Do you have the resolve and the ability to continue with your appeal? We certainly support your efforts. Best wishes!

djscal 10-26-2005 03:50 AM

Greg,

Rick got his Charite approved by Health Net after many appeals. His user id is rickz68. Send him a message, he might be able to help you.

Regards,

Dan


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