Hi all,

I don't know if this is known by the group or not, but anyone covered under the Federal Employee Health Benefits Plan (FEHB) cannot be denied coverage for the Charite ADR, provided it meets the FDA restrictions. I just found FEHB Letter No. 2001-27 that states that all FEHB plans must provide coverage when the product is used for its intended purposes and indications as approved by the FDA, if those purposes and indications would otherwise be eligible.

This is probably how federal employees are getting coverage to go to Stenum for surgery. It is on their site that they are providers for the federal employee program and BCBS Worldwide.
Wish it was that way for private insurances.
Kim

I have had the doctors office tring to authorize surgery through our BCBS program, they told me that they are not covering ADR at this time. This is a workman's comp case, but we are trying both insurances. The nurse at the doctors office told us just yesterday that BCBS posted on their website that ADR in not being paid for.
Think I will go check it out. I'm starting to think this nurse is not on our side.
Are you a federal employee? What do you do? Have you called them about this? Please, keep posting updates, and I will do the same.
thanks,
Robin

Robin,

Here are the facts, based on the FEHB letter I posted. If your insurance is held through the FEHB program, they cannot classify anything that has been FDA approved as "experimental" or "investigational." The reason for this is because OPM wants consistency in applying the "experimental and investigational" label for all employees, regardless of the plan.

FEHB carriers can still use the "not medically necessary" nonsense but IF you meet the restrictions set out for disk replacement by the FDA (one level, L4-S1 area only, etc) an FEHB carrier, by law, cannot claim that the device is investigational.

For example, take a look at Independence Blue Cross in Philadelphia.

Click on the link for Medical Policy Bulletins (accept the terms), then click on Policy by Title, then find the Artificial Intervertebral Disc bulletin. If you read this, you see that BC/Philadelphia classifies the Charite disk as experimental EXCEPT for members under the FEHB plan, in which case it's covered.

I can also understand your frustration with the Dr office. They get so many of us, I suspect, and they don't have time to learn all the rules for every insurance flavor that's out there. Nobody cares more about this than you do, so read your plan, make sure you understand the appeal process,
and don't depend on the dr office.

Hope this helps,

-stan

Thats interesting, I wonder if there is anything in place for other levels of government employees? I am employed by a local municipality government, I wonder if...

Wow, that's great news, hopefully it will help someone get their surgery approved. Bad news for us, Pat needs L2-3 done, not FDA approved. Wonder if I could try anyway??
Robin