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ouchtear 09-14-2018 07:35 PM

Has Any successfully appealed a denial in BCBS
I know that some have put in International claims and been reimbursed.. But has anyone been denied Lumbar ADR wrote a appeal and Won?? specifically NY but I would like to know any state.. It would be nice to have a list of Pre-approvals for all states for BCBS too.. Maybe this is already somewhere on the site that I have missed too... Thanks.. I am going to try for the second time in 3 years write a Appeal.. I am reading Laurie Todds book too.. If anyone has a good sample appeal that would be great too.. Of course a successful one would be golden..

tijeladeacai 09-20-2018 03:06 AM


ouchtear 09-20-2018 10:09 PM

Any? I would like to see a written appeal example that actually worked.

megatron-adr 09-28-2018 09:57 PM

My journey to get two level Mobi-C pre-approved through insurance was an absolute nightmare. The first submission for pre-approval with Anthem went through the Peer-Review (denied). The surgeon had me use a 3rd party appeal consultant that was sponsored by LDR (mobi-c mfg at the time) to attempt to get the appeal through and that 1st Level Appeal was rejected also. I was debating whether to go forward with the Final Appeal, but then decided to go visit TBI in Plano and see Dr. Blumenthal.
My thought was I would likely end up having to pay out of pocket for the surgery and they were the most experienced and reasonably priced here in the US as best as I could tell at the time (late 2016). Ultimately he thought there was no reason insurance should not approve this and his office submitted for pre-approval. It was approved within a week after a two months of constant follow up and jumping through hoops with the other submission and appeal process. Long story short.... sometimes it is not the procedure that is getting rejected, but I think it is the hospital system or the way the claim is written up that triggers a rejection.
My lesson learned.... if insurance declines it through one system... try a different system with a different surgeon. It is interesting how things sometimes workout for the best as I truly beleive I was meant to get the surgery at TBI by Dr. Blumenthal vs the original (closer to home) location.

megatron-adr 09-28-2018 10:09 PM

One other note... the policy on two level ADR at Athem had just been updated in August of 2016 as not being considered experimental and was an option available in my plan as long as you met all the bullets that made it medically necessary. I am not sure about your plan, but if it is not even in the policy for being covered as a medically necessary option then that is a whole different battle. I know the last time I checked cervical ADR was much more adopted as medically necessary than lumbar ADR. I don't think too many US insurers are onboard with lumbar ADR yet.

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