ADR Surgery Done, Waiting for Denial.
 

Hello everyone. I have BCBS as my insurer under the federal employee program. I am retired. My primary physician put me through all the paces before referring me to Dr. Kenneth Light in San Francisco, who is one of the best spinal surgeons in the Bay Area. Dr. Light reviewed my MRI and x-rays and urged me to choose the ADR choice rather than a fusion and explained all the advantages of the ADR and disadvantages of the fusion. It was a no-brainer. He went ahead and tried to get an approval from BCBS and of course they denied it as investigational. Due to my condition, we went ahead with the surgery, which I paid for out of pocket. We are now submitting the claim and expect a denial from BCBS. I really appreciate this forum and look forward to your help with my case as it develops.

Hi Vegas Guy,

For whatever it is worth, I've been told that in most cases BC/BS will not pre-authorize ADR. However, I know of people who have been told this regarding surgeons in Europe and were in fact paid after the fact. If your surgery was done in the U.S. under FDA guidelines (it sounds like it was) I believe you have a good chance of ultimately getting reimbursed. It may take a couple rounds of appeals, but I think you have a chance, especially if your surgeon is willing to assist you during this process.

The most important thing is that you had the surgery done and are doing well.

Gene

Hi Vegas Guy,
first, congratulations! I'm very jealous, as I've just scheduled my surgery date for July. I also have BC/BS and will be fighting for reimbursement. Can you tell e which level? Lumbar or cervical? One level or more?

When was your surgery and how are you feeling?

Congrats again and I hope you're feeling the relief we are all begging for. :clap::clap:

Just a reminder that some patients are getting BCBS to pay, even overseas. Maybe most of these happen because they have the special international coverage. Still others have appealed and won. People with some $ hire lawyers are often successful.

Hi and thanks. It was C5/6 which I hear is the most common. Because I had to pay for the surgery, the surgery was done in a Surgery Center rather than a hospital, which saved big bucks. I spent the night and had to be discharged in exactly 23 hours to keep it an outpatient surgery. No complications. Pain has reduced immensely but not yet totally. Good luck to you. Let us know how you do.

Thanks, very encouraging. I appreciate the supportive comments.

Vegasguy,

I know in the past, people with federal insurance through BCBS got their appeal overturned. It has to be due to federal law and FDA approval. There are people who got reimbursed and even preapproved. Go back five years or so, that is when I talked to one of the persons who was successful.

K

Federal overturn
 

Thanks for the information. I would hope there is a reference out there somewhere that alludes to Federal employees being approved for a procedure if the FDA has approved it.

Vegas-guy,

I had my ADR with Dr .Light also. He's the best. I also have BC /BS; they are the worst. I went through Two levels of appeal and then an external reviewer said they HAD pay. They had such a tantrum my bill was 135,000 and they only paid 35,0000 of the total bill. What a joke. They paid so little and made such a stink.

I know for me it took constant calling almost on a daily basis. Make sure they have ALL your medical records; tests , any doctor's seen , physical therapy , chiropractor care, medications taken and steroid injections, everything you have tried and failed. (MRIs , EMG/NG results; I THINK THESE WERE THE ONLY DATA viewed by BC /BS ; the EMG's. I have not a clue why.

What is the latest update?

How are you feeling?

Good luck and keep me posted. Feel free to PM me .

Tammi






Tammi

Were you responsible for the other $100,000.00?

Blue Cross/Blue Shield
 

Uggh! My insurance will change in a few weeks to BCBS of Texas. They have a buy-up plan & I'm hoping the international option is included. L

Vegasguy,

I looked up some information I have in my last appeal to BC. It was not BC who paid but the person (I think it was treefrog) sent me a copy of the approval letter from her insurance, Coventry Health Care, which I put in my appeal.
She was a federal employee and this is part of what the letter says:

Our Medical Director has reviewed the information submitted to include, but not limited to, letter of medical necessity, cost estimate of insurance, patient pre-evaluation questionnaire, and Plan language. The predetermination request was elevated to our Medical Director, Floyd Shewmake, MD, for consideration. Dr. S reviewed the prior determination made by our Medical Director Debra Esser, MD, and overturned her decision. He states that the Federal Employees Health Benefits (FEHB) Plan cannot deny the artificial disc as experimental/investigational if it has been approved by the FDA (Food and Drug Administration). Therefore, we are able to approve the artificial disc placement surgery as medically necessary under the Plan's contract of benefits.

this letter was dated April 23, 2009 and was to Dr. Rudolph Bertagnoli in Bogen Germany.

This is why I do not believe that an insurance company can deny any federal employee anything that is FDA approved. So keep trying, chances are you will succeed.
As for material for my appeal, I found it difficult to receive actual approval letters as people worry about the insurance companies' power to take back an approval or money. With a lot of digging, I actually got a lot of information. BTW, the lady who gave me this letter lives in South Carolina and I am sure, she would probably give you a copy if you find her on here.

Happy hunting,

Kimmers:beer:

Hey Vegas,

I am not completely sure it was treefrog as it has been a few years. If you can get a hold of her, however, she has a lot of info about ADRs and Slackwater does too.

K

VegasGuy - Do you recall what your surgeon charged, and what the surgery center charged, for your 23 hour stay C5-6 arthroplasty? Many thanks,

Vegas Guy,

BCBS paid for my two level ADR (60%) and I had the surgery overseas. Submit a claim and appeal them if they do not pay. Also, I just read recently that the FDA has now approved 2 level ADR Cervical surgery. That should help you with the claim. Hope you are doing well.

2Confused.....are you a federal employee?

Federal Employee
 

I am a retired Federal Employee.

No , I wasn't because BC/ BS is contracted with hospitals to pay only a certain fee . They charge people like you and I a super bill rate. Since , I was approved through the third level of appeals BC/ BS payed their contracted rate. I don't understand his all this works but if your insurance covers you 100 percent based on plan. Everyones plan is different and the amount they are required to pay. Example , meeting deductibles. Just because I didn't have to pay the rest doesn't mean yours will cover it too.

No I am self Employed, so I have an individual policy through BCBS.

2confused,

I too had a 2 level with Dr. Clavel June 5th 2013. I a;leo have BCBS and own a small business in PA. My Ins co is having the first review this coming Friday.
Keep your fingers crossed for me. I did PM you the other day for any help you could provide.

I am hoping to win this round since now i need two level in lumber L34 L45. Not sure how long I can hang on at this point with not getting intervention. cannot even get a flight anyway before Christmas or more to the point afford it at 12500 per ticket.

Any help would be greatly appreciated per my PM.

Frank

I hope you are right. Thanks for the info.