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-   -   Florida Blue - Denied ActivL Lumbar TDR (https://www.adrsupport.org/forums/showthread.php?t=13629)

Nestletea 02-13-2017 06:40 PM

Florida Blue - Denied ActivL Lumbar TDR
 
I had lumbar TDR scheduled February 15, 2017 with Dr. Rolando Garcia in Miami, Florida. Their office submitted for approval and the procedure was denied due to being "experimental/investigational." I then submitted an expedited internal review. Florida Blue had 72 hours to make a decision and I was again denied. This was after I sent in approximately 1000 pages of medical records and my surgeon completed a peer to peer review twice. The first peer to peer was done unfairly (family physician to surgeon). My surgeon then asked for a second peer to peer review with another board certified spine surgeon. Florida Blue again denied the procedure. Today I sent in an Expedited external review. This contained all of my medical records, 25 research studies that favor lumbar TDR vs fusion and all of the insurance companies that offer positive coverage (this includes some BCBS plans). There is another 72 hours to make a decision. If anyone has any other suggestions, it would be greatly appreciated!

Thanks

WakesurfMike 02-15-2017 11:00 PM

you can file a complaint with your States insurance consumer affairs
 
http://www.myfloridacfo.com/Division...eedourhelp.htm

you can file a complaint with your States insurance consumer affairs

WakesurfMike 02-15-2017 11:17 PM

maybe a lawer or activL® Artificial Disc Patient Assistance Line (PAL):
 
I found this recommendation for a lawyer that will help with getting insurance to pay from Dr Bertangnoli web site. I am sure it won't be free.

http://www.dr-bertagnoli.com/patient-information.html

David Suddendorf, Attorney-at-Law
415.806.6599
dave@davidsuddendorf.com
http://davidsuddendorf.com/adr-insurance-reimbursement/

Have you tried the Active L Patient Assistance line? They have staff available to help free of charge. You would have to get your surgeons office to call the them.

https://www.soactivesofast.com/low-b...nt-information

Resources include:

A reimbursement support line for pre-authorization, appeals and external review
Template letters, coding guide and supporting literature
Ongoing reimbursement landscape monitoring and analysis

activL® Artificial Disc Patient Assistance Line (PAL):
Monday through Friday, 9:00 am - 6:00 pm ET
Tel: 844-245-1140
Fax: 844-285-1330
Email: cynthia@patientassistanceline.com

Nestletea 02-22-2017 06:28 PM

Expedited External Appeal Denied
 
My frustration has continued, as the expedited external appeal that was filed through Florida Blue was denied. This has exhausted all of my insurance options in the United States. Therefore, I will be headed to Barcelona on March 13th to have a lumbar ADR with Dr. Clavel. I have thoroughly researched the neurosurgeons in Germany and Spain and based on patient outcome and insurance provided by Dr. Clavel's office for the surgery, the decision was easy. Also, I have researched the activL and M6L and discussed both discs with several US and European surgeons. In the end, I will go with the M6L. This disc has an 80 year lifespan vs. the activL that has a 30 year lifespan. I feel at peace with the decision and look forward to feeling better in the near future!


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