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-   -   Insurance Decision Dragging On....... (https://www.adrsupport.org/forums/showthread.php?t=6099)

CindyLou 04-02-2007 02:31 PM

Hi everyone,

Cindy here. Well, no news is good news I guess. My husband gave his boss the folder I had compiled all weekend for his review, and he said he wanted a couple of days to read the information, with the assistance of HR dept. head. He commented he was very interested in learning more and appreciated my organized data. (per my husband) I am trying to remain hopeful. I am choosing to believe I have some momentum working in my favor. The HR lady asked for the name and contact # of my assigned case manager thru HealthPartners (I had requested a case manager weeks ago to help advocate for me). My husband left for New York so he and the boss and HR have one final meeting on Thursday morning for review. I haven't received that package yet Harrison, that you recommended, on Long-Term Results of Lumbar Arthroplasty-Roundtables in Spine Surgery. Maybe if that shows up, I can drop it off at the company, for more information his boss can peruse. My stomach has been in knots all day. I feel like I am groveling for this surgery. I am groveling for it. update: QMP just called and are just now processing my order for that article, but I told them to go ahead and send it. Maybe I can get it in his boss's hands tomorrow afternoon. Does this still sound hopeful you guys? I need some confirmation that I still have a shot getting this covered. Hope I'm not deceiving myself. I'm just very anxious for an answer, one way or another. Sorry I'm blabbering.

Ilene 04-02-2007 02:53 PM

Unfortunatly, this is a big problem. My 5 level surgery in November cost 69,000 Euro's (just at ($90,000) plus airfare for my husband, father and myself, plus, plus, plus...We are still attempting to work this out with the insurance company but, now with the use of an attorney.
Good luck.
Ilene

CindyLou 04-03-2007 06:17 AM

Ilene, thanks for the response. What 5 levels did you have surgery on, and what surgeon? Most importantly, how are you doing? I hope you continue to heal well. On the insurance note: I had emailed my doctor here last night, asking if he would write a "no holds barred" letter stating his recommendations for my adr. He responded so swiftly last night (God love him), and composed a strong, I hope convincing, two paragraph letter. So, one way or another, I should have an answer by thursday. Good luck using the attorney...hope that bodes well for you! Cindy

kevin bosse 04-03-2007 03:45 PM

Hi Ilene (sweetcheeks)
I think persistence may pay off with the insurance end of things . We received monies from our insurance this week ,but not much .A total of 2,500 dollars .This was just some of the cost for anesthesia.We were denied our first claim,of $38,000 now my wife has a rep. from bcbs and we have a letter mailed to our state representative. We don't know where it is going to take us but a little money is better known
Someone one on the forum mentioned that the insur. co. don't have codes for a.d.r and my wife is using that info. to help us out .I'll let you know how we make out.

CindyLou 04-03-2007 08:02 PM

The publication that you, Harrison, directed me to, via QMP, titled RoundTables In Spine Surgery;Long-Term Results Of Lumbar Arthroplasty arrived today and absolutely exceeds my expectations. Have you seen this yourself? Likely. It's fantastic. If this, along with the Dr.'s letter, does not approve my surgery, I don't know what else I can do. It's hands down, the best thing I've read that supports long term results of lumbar arthroplasty. Thank-you for helping me get my hands on this. If this succeeds, any and everyone who is still trying to get covered or reimbursed should purchase this bound booklet. I guess we should wait and see. In any event, it is reassuring me of my decision to have adr two weeks from today, regardless of compensation. Thanks again. Cindy

chasswen 04-05-2007 12:50 PM

cindy
so whats the word are they going to pay?
chuck

Ilene 04-05-2007 06:04 PM

Cindylou, my surgery in Stenum was after having had 4 previous surgeries in the U.S. I had 3 surgeries in Stenum (7 in all). My spinal issues started with a 12 cm mass at my L4 - L5 level and my last ditch hope for recovery was Germany! However, the doctors made me come over to their facility 1 week early so they could perform their own tests. They were not sure that they could help me up to that point. So, I went to Stenum with blind faith. Yes, they decided that they would do the procedures with reasonable belief that they could give me relief.

The 5 ADR were: C3-4, C4-5, L5 - S1, L3 - L4, L4 - L5, plus 2 cages, and refusions (3x) L3 - L4, L4 - L5, C5 - C6, C6 - C7.

Our 'argument' with the insurance company was many faceted:
1.) this was the 3rd time that I have had to have refusions. The fusions were not holding and were backing out. The first time that this happened one of the screws broke loose and backed down in to a major muscle (hip); and
2.) NO ONE in the U.S. was willing to handle my case. Mayo Clinic sent me around and around not knowing what to do with my case. Records documentation exist.
3.) Had other options been available to me in the U.S. I would not have gone to Germany. This was my last ditch effort to try and get any improvement with my spinal condition; and
4.) Our insurance company not only turned us down, but also stated that any subsquent medical claims related to my spine or medical issues resulting from the spine will not be covered. This is the biggest reason we are using an attorney. We cannot afford for me to be uninsured when insurance is clearly available to me.
etc., etc., etc.

If anyone does know the name of a top notch spinal specialist - anywhere in the U.S. please let me know. I would feel better knowing that there is a doctor available to me in the event of an emergency within the continental U.S.

Ilene

CindyLou 04-06-2007 11:16 AM

So, here's the "official" scoop on my healthcare provider's decision, along with my husband's boss' input: trust me, it's convoluted, so bear with me. HealthPartners (HP from here on out) has "officially" turned down my second appeal, w/ exception being they will pay for the fusion part (this is if Dr. B. discovers he has to fuse my L6-S1, partially sacralized segment during surgery). Dr. B's office would have to break out costs associated with it, and HP stated by agreeing to pay fusion part (if needed) they will pick up costs of my hospital stay, the fusion, attending physicians, pt, any anesthesia, recovery in hospital, etc. And all we would have to pay would be for the ADR's themselves (what does a prodisc run? Anybody know? In Germany, not states.)and Dr. B's time on their implantation. (so of course, I'm thinking, fuse the son of a bitch)

Secondly, and I still can't wrap my head around this logic, but they decided (HP, the boss, and HR)that were the boss to decide to "over rule" HP's decision for denial, and make an exception, then this reimbursement of the procedure would be subject to IRS taxing and would have to be declared as income. (???) Is that a true statement, anyone? And if HP were to reimburse us it would establish a precedent and the boss does not want to set a precedent for other "unusual or extraordinary claims." that's a quote.

And finally, because the boss feels so bad about this (yeah, I can tell, the tears are running down his face already) and does not want us to have to bear this completely by ourselves, (even tho he explicitly told Rick the other day, he could pick up the phone and just tell HP to cover this for Cindy,if he wanted to, which was a "tease" to me) he has offered the following: 1. Pursue the MN Dept of Health option. If they direct HP to pay, it would be done on a non-taxable basis. (I told my husband I have run out of steam, and if he wants to pursue that avenue, go for it) 2. our medical expenses will be tax deductible for year 2007 (duh, not stupid Larry) and gov't will reduce our tax burden by 35-40% for our out of pocket. 3. lastly, (finally a bone tossed our way) the company will reimburse us for 50% of the costs that we have for out of pocket, meaning whatever the total bill is minus what HP chips in for the fusion (if performed) , the company will pay us a check , which still means it will be taxable income.

Whew. Better than a poke in the eye as they say. By my husband's calculations, between the amount that the medical deduction should save us on taxes (about 35% of the amount we pay), plus the 50% that the company will reimburse us for, we should eventually come out with about 85% of our out of pocket costs recovered. (by next year, of course, this time)

I am no accountant, so all I can say is, "I guess so." All in all, we are talking about not getting reimbursed for the tax deductible part until almost a year from now, if my calculations are right.

So you guys tell me.....a win or a lose? My husband thinks it's not a bad deal. I think it sucks, because I presented such strong material in favor of my adr procedure and adr in general, for you guys as well, who are fighting the fight too. The statistics I gathered were there. I honestly don't know, how in good conscience, they could turn it down as an "unusual or extraordinary claim." Where is the burden of proof there? Sorry this is so long. I cried and cried and cried some more yesterday. And how did I find out my disapproval? Through HealthPartners? No. An email from my husband!
They can all go to hell as far as I'm concerned. (sorry to whomever that might offend) I have it off my chest, and now I have to think good thoughts, feel at peace, all that good karma, because I leave in one week for my surgery. So, I ask you guys once again, what do you think, a win or a loss? (to me, big picture, it's still a loss, anyway you cut the pie)

chasswen 04-06-2007 11:25 AM

cindy
sorry to hear of the outcome but at least there going to help. as my boss told me they would help and poof no help.
i am selling my house to cover all the expenses and moving to sc
single prodisc-l in aug was 4500 euro about 5800.00 usd
chuck

kevin bosse 04-06-2007 11:42 AM

Hi cindylou
We too ,my wife and i are fighting the insur. battle.We were denied our first claim, and have been in touch with our local congressman to start our second battle .We did receive some monies, but about 1% of total cost WOW!!!!
I had 3 levels done in germany , and like you the insur. company says it was unnecessary surgery.
since when did Blue Cross receive there doctorate degrees .From what I gather they do not have a CODE to put A.D.R under,I say put it under Fusion you morans.
We wrote a huge cover letter to the congressman who is going to see it gets to the correct people.It's not as if we have any clout,we're just regular joes who want to be compensated for a procedure that was deemed neccesary you insurance morans.Wow i feel much better
Let me know how you make out

Terry 04-06-2007 12:07 PM

CindyLou:

I am also sorry about the outcome. I understand the pain you must be in but I encourage you to not give up on yourself. I was forced to deal with my medical condition by my employer placing me on medical leave. I am the executive director but I answer to a board of directors. I had to make the decision and pay out of pocket with no guarantee of my lawsuit or insurance settlement.

Ultimately I had to make the decision that I thought was best for me; i.e., No Fusion Period! It cost about 64,000 and had to be paid up front. I do not regret the decision today as I stand upright and am in significantly less pain than pre-surgery.

"Illegitimi non Carborundum" - Don't Let The Bastards Grind You Down.

Do what is best for yourself and the rest will follow. You have one spine = one life. You may sacrifice now and look at it a couple of years from now and realize that ultimately the quality of your life is all that matters and there are no guarantees.

Good-Luck with a very difficult decision and believe that many are here to support you in the process.

Go with God Cindy.

Terry Newton

CindyLou 04-06-2007 04:13 PM

Chuck, Kevin, and Terry.....thanks for the comments, support, etc. I had to already wire the full amount 3 weeks ago. Didn't you guys have to do that? At least at Pro-Spine, that's how Dr. B does it. I have made my decision to go ahead and have the surgery, obviously. I cannot allow anyone else to decide my fate, but I have to admit, for a few crazy, delirious, rage-filled minutes last night, after getting the news (still haven't heard from them directly..meaning HealthPartners) I was more than tempted to cancel my surgery, get a refund, be in more misery, get on stronger pain meds so I could sue the company for denying the surgery and contributing to an addiction to narcotics....and of course, it was all just being stupid, idiotic, my way of coping and how could I stick it to HealthPartners and the employer. I've had time to sleep on it, work thru some of my disappointment, and obviously get a clear head. (now I know for sure, after sleeping on it, it's a good plan! Ha! Just kidding!) I'm not a bitter or revengeful person by nature. It's just so wrong and unfair. I'm sure none of us like being unheard. In all my wildest dreams, I never could have thought this one up...that I would need a back surgery in America, sanctioned by my back surgeon and deemed medically necessary, only to have this same country deny me coverage! I feel like I'm living in some 3rd world country! Enough ranting and raving. I leave in a week. I refuse to utilize it starting another final appeal with the Minnesota Dept of Health, when I need to be just packing, reflecting, being positive and thankful for what's in front of me. Boy, thanks for all the support. I do appreciate it.

Judy 04-07-2007 04:13 AM

Cindy if I understood correctly they will pay for the fusion correct and all associated costs. If you were to get a fusion at one level (hear me out)
they will pay:

all Hospital costs
all surgery costs asssociated with this correct?

That to me means you pay for the ADR only, if so you pay say $4000 each then the employer will reimburse you 50% of that cost so say you have 2 and it is $8000 then besides travel expense you are down to $4000, sound much better than most people have gotten?
Few insurance companies are paying, I realize it is still alot of money but I think you must have done a great job explaining ADR and what the benefits would mean or they would have just denied you.
I got Cigna to pay for my fusion part and had Dr. B office itemize the fusion hardware from the disc hardware on one invoice, the second invoice was for the hospital bill and last was for the doctors. They then paid for everything but the disc and after about 6 months after payment they are now claiming they over paid. We just told them they needed to provided documentation to us showing an overpayment and they never contacted us again, this was about a year ago and I don't know if there is a time limit on this and of course don't want to call them and ask the status so we have needed to hold onto $10K in the bank in case they change their minds.
Did I misunderstand what they offered you?

CindyLou 04-07-2007 08:38 AM

Judy, as far as my understanding of the conditions for them paying, I think that is what they are saying. A few posts earlier, I think it was Kevin saying last August one lumbar prosthetic device was going for about $5800. By now, I'm going to guess $6,000, so x 3= 18,000 we have to pay. (which like you said, money is money,but in my book, $18,000 is still alot and we're not done calculating yet ). Then, the kicker, we also have to pay for Dr. B's incremental expense for the time it takes him to implant them. My guess is it's going to take a whole heck of alot more time to implant those (since I need 3 lumbar discs replaced) than to do one L6-S1 fusion. (if it is deemed necessary) But, let's play off the scenario that I do have the one fusion...and no additional costs (i've already prepaid Pro-Spine $50,000 for the down payment),so by my calculations $50,000-18,000=32,000 refund minus Dr. B's time, for installing 3 adr's = the million dollar question!...I have no idea. Let's throw out a crazy low number: $10,000 for his time. (this may be laughable) Then you take that to our equation table: $32,000-$10,00= $22,000 coming our way. Finally, if those are our out of pocket expenses and the co. pays half of $22,000+ 11,000=$33,000. Then we are finally only out $17,000 out of pocket.(50-18-10+11= 33) And what if his time is way more than $10,00? Of course this is not taking into account 3 week hotel stay, food, airfare, etc. You are right...it is better than nothing. I'm not denying that. I just really wanted a big win, a win that would help pave the way for all of us needing ADR. I had my sights high,no doubt, like everyone I'm sure; I really researched, and wrote a thesis on my insights and personal history, like everyone else I'm sure. Insurance is just dragging their feet! The statistics are there! They are just hiding behind experimental and investigative! The big question: how long can they hide?? That's it. That's my story and I'm sticking to it. Thanks for your input Judy. Totally changing the subject: is it possible to pull a loose top over my head after lumbar surgery, or should everything be front buttons and zippers? http://adrsupport.org/groupee_common...icon_smile.gif

CindyLou 04-07-2007 08:42 AM

Judy...p.s. possession is 9/10's of the law! Take the money and run! ha-ha. (if you haven't heard from them by now I doubt you will)

Judy 04-08-2007 03:17 AM

Cindy I agree possession is 9/10's I just wish I knew if they are dropping it so then I could pay the balance on my home equity that I owe for surgery. There must be a law somewhere about this but I researched and could not find anything and I surely don't want to call them and ask.

Hoping you the best this week I am sure everything will work out for you.
Judy

CindyLou 04-08-2007 01:09 PM

Judy, yes, of course, you want to put it to bed. Surely, somebody out here in forum land is an attorney or knows someone who knows someone that is an attorney. Anyone? If Judy got her insurance reimbursement and over a year ago they contacted her saying they over paid her by, what was it, Judy, $10,000? and now she has not heard anything else from them in over a year's time, should she still be looking over her shoulder (legally) for them to confiscate their funds? Who has the answer??

Judy 04-09-2007 07:31 AM

Thanks Cindy maybe someone knows. Like you said it is like we are always wondering if they will or can come after us. I was hoping there was a time frame where they cannot persue this. It is just strange that we have not heard from them in so many months.
Is $10,000 worth taking us to court, I don't know? It is Cigna Healthcare and I think they are the worst. We had to fight this for about 14 months to get payment and the only reason I think they did pay us is that I believe because I got the States Attorney their help I probably would have never seen any of it.

Oh well I guess I have to keep holding onto it. My husband claims we will persue this as long as they dragged their feet to pay us anything.
Cindy good luck this week I am sure everything will work out fine, worry about your surgery and try not worry about the cost, remember you only have one back and your health is more important than the money.

Time will tell I guess.

Judy

CindyLou 04-09-2007 04:33 PM

Judy, thanks for the kind words and encouragement. Am getting a bit edgy, with surgery around the corner, but had the most amazing day today in spite of myself. I must have had at least three perfect strangers tell me they were going to pray for me and my surgery, while I was out and about w/ my college son home for Easter break. Perfect strangers. Amazing. And yes, we will get an answer for you on this insurance nonsense. Where abouts in Connecticut are you from? I ask because my husband is from Glastonbury. All his relatives still live there and in surrounding area. Anyway, I still have not received any official denial from HealthPartners! No letter, phone call. Just what my husband heard at work and emailed to me. How disappointly unprofessional is that?! I must take a deep breath and get over it.
Take care! Cindy

CindyLou 04-09-2007 04:38 PM

spelling correction...disappointingly. I should have been an editor! I'm a knucklehead for spelling and grammar! http://adrsupport.org/groupee_common...icon_smile.gif

Cindy

Judy 04-10-2007 02:10 AM

Cindy, I am from Wallingford which is just south of Glastonbury. This is about a 15 minute ride via the highway. We actually go to Glastonbury to an italian resturant that we like called Max's your husband probably has heard of it. Do you ever get a chance to come to Connecticut?
Try not to get very nervous just remind yourself you are in the best of hands. You have one back and remember you are doing the best you can to make it 100%.
I cannot believe it has been over 2 years since my journey to Europe for the same type surgery and believe me I am much better for it and so will you.

Judy

CindyLou 04-10-2007 06:07 AM

Hey all, have my bone density exam this morning. Hope there are no surprises there. Did have one a year ago (very early, early stage of osteopenia diagnosed), so hopefully I have not headed south too fast. See this extra crap women have to heal with?! Bone loss, especially in our 40's and 50's, with onset of menopause and downhill slide of our estrogen levels. Can't take hormone replacement anymore,nope, cuz that might kill us too. I guess one must guzzle milk and D supplements till the cows come home, no pun intended! Ha! Report in later....note to self....p/u more ointment for gross lips!

CindyLou 04-10-2007 04:07 PM

Hi everyone, had my bone density exam today, and have actually improved since last year, which was great news. I was a bit worried but came thru w/ flying colors. I believe that is my last exam/procedure I have to take care of before I leave Saturday for Germany. Whew. I'm actually mostly packed, so now I can do something fun like get a pretty pedicure! God forbid Dr. B should operate on me w/ ugly, unpainted toes! lol Well, that's about it. I might drop in once more before I leave. And I will certainly do my best to keep everyone updated post-surgery. Thank you for all the support that's paved the way for this decision. My only regret w/ having to go abroad is naturally not having my grown children able to come and visit. But I know it's a small price to pay to have Dr. Bertagnoli perform this surgery. Enough said. (remember, my surgery date is moved to Monday, April 16th) http://adrsupport.org/groupee_common...icon_smile.gif


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