Well got a call from the state dept of ins and they agree with the ins co that ADR is experimental! I guess all you recipients and your docs are bucking the powers that be! You're all so lucky that your coverage has joined the 21st century and is not stuck using leeches! Now I'll be paying out of pocket and no recourse except the courts. Hope others have better results than I did.

Missy

Awwwwww Missy I am So Sorry to hear that...So UNFAIR! I just can not wrap my head around the fact that BCBS can ok this surgery in their other states. And you are a case study in yourself having had the fusion. I really hope you have the energy and your lawyer can just sue the pants off them! Your appeals where superiorly written.....I don't think you could have done any better!(((Hugs)))I will say a prayer for you.I hope you keep up the good fight!

Janey

Missy,

Can you explain a bit more? Did you have your appeal reviewed by an independent third party reviewer? This is another process that you have a right to pursue. In fact, the overturn rate may be up to 50% in some states...

My appeal was also turned down at the state insurance board level--over HealthNet's objections, they did send it to an anonymous reviewer identified only as being an orthopedic spine surgeon associated with a medical school. His comments indicated he either didn't read my appeal or chose to ignore all the points I made, but his opinion was that the procedure is experimental and according to my insurance contract, HealthNet was justified in denying the surgery.

Rich

It was the independent hearing. It was to the CA state dept of ins, they call it an independent medical review. I have not seen the denials yet, they are in the mail, but apparently the 3 docs, one NS, one ortho and one PM were not impressed by my argument. I refuted the definition of "investigational and experimental" and showed them loads of articles in favor of CADR. I'm guessing that the 3 docs were old school and don't know enough about ADR to do it themselves, so they rule it all "experimental". I'll fill in more details as the paperwork reaches me. I thought I wrote a very well thought out argument and backed it up with peer reviewed articles and expert opinion as they required. Go figures! Maybe CA is not one of those 50% states. They don't have to tell me the percentages of overturned denials. MORE SECRETS!!!!!!!!!

Missy

Janey

Thanks for the hugs! I really needed them!

Sahuaro

I'm thinking that my docs were equally unimpressed or didn't really read what I wrote. I'll keep you posted.

Missy

Missy,

Sorry you had the same experience as me a few years ago. (also CA) Seems nothing has changed. I was just as frustrated as you. You just have to find a new angle to get ADR coverage. I really really recommend finding a way to get Aetna ins.

LBP

Missy:

I am so sorry to hear about your denial. I hope you continue to fight this as there is no good reason to deny this surgery other than greed as they don't want to pay; period. But please keep paying your insurance premiums and remember; "We love you; the customer." Enough people need to stand up to them and punch them in the nose. It's the only way you get their attention.

Hang in there and know that we support you and are there for you.

Terry Newton

LBP

Sad that things have changed so little over the years isn't it? It's too bad these docs don't keep up with the latest technology after they leave practice and then decide that something is "experimental" when thousands of surgeons are using the devices. In November when I can change ins cos, believe me I'll be checking on the current status of cos okaying ADR!

Terry

Thanks for your kind words. I'll have to take them to court now as that was my last gasp for appeals. I wrote such a good one, too!

Missy

sahuaro

I wonder if you can file a Freedom of Information Act ("FOIA") request to determine the identity of the anonymous reviewer. It seems to smack of lack of due process (violation of Constitutional law), if I don't even know the name or credentials of my reviewer. I wonder if you would consider checking with your local law schools UofA or ASU and see if they have a legal clinic that would help you with the FOIA request.

Of course you're going to get denied by an anonymous reviewer! Does anyone think he/she would be hired again, if they agreed with your ADR appeal?