Optima - Denied
 

Just got the letter back from my insurance company: Denied.

Denial codes: "D84F - Not medically necessary per Medical Director - Member responsible."

"The requested service is considered investigational and not medically necessary per Optima Policy Surgical 78".

What a surprise... :)

Are you going to appeal?

Romakis,

This may or may not help...see attached. Make the calls / letters anyway. It's a small effort that have a big ROI.

Appeal
 

Yes, I am going to try to appeal. Thanks Harrison.

Help
 

If anyone has any documentation to help me file an appeal, I would highly appreciate it. Please let me know and I will give you my e-mail address. Thank you all in advance!

I called my insurance yesterday, and after 30 minutes of run around they gave me a name of the doctor who accessed my claim and made denial recommendation. I googled this doctor's name and this is what I found:

"Dr. Peggy Ebinger, MD is a psychiatrist in Virginia Beach, Virginia."

:clap::clap::clap:

My appeal package
 

Sending the documentation today. Thank you all who helped me put it together (Jerry, Andi, thank you so much!!!).

Had a hard time finding an envelope to fit all the paperwork... :laugh::laugh::laugh:

Wow, so the person making the decision was a freaking psychiatrist?! I'm entering into my own ADR denial hell, so this is good information to have.

Appeal is also denied
 

As I expected, the appeal was denied as well by Optima Health. They stated that it was not "medically necessary", and that discectomy should have been used instead :jacks:.

I guess I should have cut the rest of my discs out, and leave everything else as is :jump:.

Man, my appeal was so thick and looked so good :)...

That really sucks!!! Sorry to hear...

So sorry to hear this! I lost my appeals too, and I'm now the proud owner of a janky ACDF.

https://scontent.fphx1-2.fna.fbcdn.n...d1&oe=57AEC0B1

https://scontent.fphx1-2.fna.fbcdn.n...2f&oe=57AFC765

janky fusion
 

Makes me so angry that the system makes us chose not the best options... I hope you heal well...

That sucks insurance won't pay, but they will pay for a procedure that has a high rate of adjacent level disease in the future. An ortho that I know said the policy may be due to the fact that in an ADR, the surgeon needs to clear out any bone spurs or deposits, etc. That way everything is nice and clean. In a ACDF, its not done as there is no more movement, so its an easier surgery and everybody makes more money.

I'm actually currently freaking out about this. My surgeon said he cleared the nerve exits on both sides during my surgery, but post-op I still have horrible radiculopathy in my right arm. He said he thinks it's from cord compression.

Last week I finally got out of my cervical collar and got back driving privileges, then ended up with a bunch of weird new symptoms. Surgeon ordered me back into the c-collar and to go get a new MRI ASAP...three days after I called to report the new symptoms.

Got the MRI yesterday, and he was supposed to review it today and call me...but never did (trust me, I called the office five times to try and make it happen).

However I did get the radiologist's report, and this is what I find:

pre-op MRI report for that level: C5-6: There is a broad-based disc extrusion eccentric to the left, resulting in spinal stenosis with cord compression. There is a moderate right neural foraminal stenosis secondary to uncovertebral joint arthropathy.

Post-op report: C5-6 intervertebral postoperative changes of ACDF. The spinal canal is widely patent. Right-sided uncovertebral spurring results in mild to moderate right neural foraminal narrowing. The left neural foramen is patent.

Tell me if I'm reading this wrong, but it looks like he did NOT remove the bone spur on my right nerve canal at all!!! And I still have horrible right arm pain plus all these new post op issues from the stupid ACDF and what turns out to be an oversized PEEK cage (you can actually see how big it is in my images).

The nightmare never ends and I don't know what to do :'(

"psychiatrist"
 

Sorry to hear all the crap you are dealing with, sounds like some of the CA criminal work /comp system garbage I am going thru and have gone thru. People who do not understand and have never dealt with this type of trash can not even imagine it even exists. They would probably not believe this if they read it for themselves!! HANG IN THERE !!!!!!!!!!!!!!!!!!

"Dr. Peggy Ebinger, MD is a psychiatrist in Virginia Beach, Virginia."

Do another appeal and don't give up. I won on my third appeal.

Anither Appeal
 

Thanks, but what else could I possibly add to the paperwork? I already submitted over 50 pages. I have no idea what else to add to it...

If I recall when I was dealing with denials, each time they gave me a different reason for denying. Make sure you're providing evidenced backed practices to refute the denial. Don't forget to include articles that show ADR is less costly and healing is faster thus saving insurance thousands of dollars in the long run. I also contacted my congressman who helped me tremendously since my insurance is Tricare and my injuries were all service connected.