Henry....sorry to hear that you were denied, though this is only Round 1. It appears that not only did BCWW disagree with the "medical necessity", which your Doctor clearly wrote in his letter, but they tie the medical necessity to "the type of service rendered". This implies that you did need treatment but may not have needed ADR. This is just my take on the denial. For example, if you had obtained fusion surgery, BCWW may have approved this "type of service" as a medical necessity.

I wish you luck in the follow-up appeal. I am quite interested what other members like yourself include in follow-up appeals when their first application or appeal is all inclusive. Does anyone have thoughts on this?

Optimistic, I think you are right - now that I look at it again. Although in my actual phone conversation the person I spoke to was emphatic about the 'emergency' thing. He actually said to me that if the surgery was performed as the result of a car accident (for example) that I would have been covered. But in their statement as you point out the 'for type of service rendered' seems to be indicative of what you are saying.

Yet there are some like JasonHHH who had same procedure and he wins without appeal needed. :insane:

Henry, I have yet to send you my info, but I will! Just a note, make sure you write down who you spoke with at the insurance co and even record the conversation if you can... If the employee tells you something, even if it is false (but in your favor) a lot of the time they will honor it...but you have to have proof.

From what I'm gathering, it does come down to the emergency vs. planned. If it's emergency surgery then they will cover it. If you try to get pre auth, then it seems that they make you follow the regular guidelines of what types of surgery is normally covered. But I also agree that there doesn't seem to be any rhyme or reason. My policy just renewed and this year there is no penalty not getting pre approval. I'm just going to pay for it out of pocket & hope that there's enough to support that it was an emergency. :(

This is correct, it might be hard to get them too do it but technically they are supposed to honor it. I don't know much about the health insurance but I have taken licensing exams for property & casualty insurance. It's called estoppel, if an insurance employee gives you information and you acted reasonably based on what you were told, they have to honor it. I've also studied it in my law classes, under the estoppel doctrine a company is liable for any damages that you suffer if you are misinformed.

I feel very good about the construction of my appeal. Kelly I know you are going to send me your docs, but in all honesty I have done a lot of background work on my own and I have consulted with an appeals specialist or 'advocate' if you will. I have (patting myself on the back) very good writing skills, and my main letter is coming along great.

I know when I say this, many will scoff at the notion that I am extremely confident that I will win my appeal, but I am. I should have it out within 2 weeks. I forgot how much time they are given to review, but I will keep everyone abreast when I win, I will then share my experience.

Hen

Hi Henry,
Any progress on your appeal letter? I am preparing for an appeal as well and "putting all the ducks in a row". I have some good references provided by Colorado Babe as well as my own research. It seems like the outcomes can vary by insurance carrier, pre versus post authorization, type of surgery (e.g. cervical or lumbar, one-level versus multi-level, etc.), level of support from local doctors, and many other factors. In spite of this, there is obviously some randomness in the outcomes.

It is very hard to predict whether the appeal will be successful. However, I still wish you luck Henry and pray you will be approved.

They are nuts
 

Opti and Henry,

Not to be a downer but they will try anything they can to not pay.

Opti you are correct regarding emergency. It still doesn't matter. Just went to my 2 level in person and they fought me all the way. The Doc on the panel couldnt believe his eyes when I walked in. then was in total disbelief when they found out I had the neck done as well 6 Months prior. He actually nodded his head and smiled in approval.

I have and had all documentation and 3 letters from the surgeon. With the last one stating exactly that Emergency along with 8 exhibits all bound nicely for each member. Their jaws dropped when I pulled all the stuff out. Cauda Equina Syndrome is a clear emergency under any curcumstance. Now I am not sure as to the outcome yet since they have 5 days to finalize. What I can say is you need to use the handbook against them. They will find any small thing to wriggle out of paying. I have read this book cover to cover and flagged everything. I found some interesting things of which would be a no brainer to beat them with their own book. Wont post it here to broadcast but I know 100% if they deny me again I will win with the Insurance commission and plan on taking them to task.

For me its sport. All upside since I could really care less about the money. Yes I would like to get it back but Im having fun with this!!!

More to come. I hope you guys make out well too.

F

Heh. You're a sick man Frank. Making sport. I like it! :chainsaw:

Yeah, at Kaiser when I showed my doc the images he, too, had that kind of kid in a candy store fascination about it.

Poor US docs, they're handcuffed and can't play with the big kids on the upper playground.

very good stuff. I have taken a lot of good advice from Frank and others. I am exceedingly confident that I will beat the odds. I have been pouring myself into this appeal. Good luck to you Optimistic as well