Sorry in advance for this long post.
I also have questions I sent my invoices for the fusion portion only to Cigna back in the end of December. I finally heard about two weeks ago that they were dening the claim due to artifical discs being experimental. First I never sent them anything that was for the disc, all invoices were for the fusion portion of the bill. I had the disc invoces separately and did not send this invoices. How did they find out that the surgery also included the artifical discs?
I then called and I am only allowed to talk to customer service and not anyone that actually reviews the file, I believe this is wrong due to my circumtances looking only for payment for fusion. I had explained to her that fusion surgery has been done for years and it is not experiemental and asked what they needed from me know. She told me any doctor opinions notes etc. I then forwarded the medically necessary letter my state side doctor wrote (Dr. Yue) along with another doctor findings recommended a three level fusion to them. I also explained that I do have another invoice which I did not send for the discs and that I was only looking for payment for the fusion portion. I really never received any response from her, she only .
said they would review the information I provided.
Now yesterday I received a letter from them asking me if Dr. Yue is authorized to represent me in making this appeal. If so do nothing and if I do I will not have another opportunity to appeal the initial coverage decision following the completion of the two level appeal process. If I revoke the authorization for Dr. Yue to represent me before the aapeal process I then can pursue any remaining appeal rights, whatever that means.
does anyone understand this or have any suggestions as to what action i should do?
Thank you in advance for listening and any suggestions you might have.

Judy

CIGNA is very difficult. That's what I have.

Sounds like they have denied your request and now have you in the appeals process. It is not fun or promising.

The final step is the 3rd level appeal which is an independant review. That decision is final. At least this is how it works with CIGNA of Colorado.

However, your best chance is in the 3rd level appeal since the decision is made by an outside physician appointed by the state. You have to make a good case that this is the best treatment you could have gotten and was the one with the most efficacy... That is what I'm working on as I try to get pre authorization.

Brady

It seems they have denied

Keep pressing. The customer advocate that I talked to today at CIGNA said they are getting more and more of these requests for ADR. She thinks they are about a year out from accepting them as a normal practice and that each case is judged individually until then.

Brady

I contacted them again today (Cigna) to explain that a spinal fusion is different than ADR and I might have gotten through to them. I also contacted United Technologies (husbands employer) because they are self insured and they have an advocate group also that promised to find out what is going on and the fact that I had fusion also and see what they can accomplish. They advised me that I would hear by Friday, I will not hold my breath. I also said that if they want I can send them the bill for the artifical discs and they can pay that also since that is what there rejected and they did not even receive that bill from me.
Oh well wish me luck. I am only trying to get them to pay for the fusion that is what is so fustrating, I am not even asking them to pay for the artifical discs.

Judy

Judy, why not ask for the whole shibang? What have you got to lose!? http://adrsupport.org/groupee_common...n_confused.gif

Good luck either way!

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

Harrison, I finally said that to both of them once again explaining that I never gave you the bill and I asked "I can send it to you and you can have them pay that also since that is why they are rejecting my claim"? I did in fact send it to them so they would believe I actually had another invoice that I paid which I did not send them for payment. So we'll see, it is just annoying how I can get rejected for something I never put a claim in for? Does not make sense and it is even harder to explain what was done. Let's see if they can help if not I did talk to someone yesterday with the State of Connecticut and she also said she would try to help and she is suppose to send me the information they need, not ready to give up yet.

Judy