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-   -   Denied! They'll wish they hadn't... (https://www.adrsupport.org/forums/showthread.php?t=9126)

sfmcfar 05-11-2005 07:34 PM

To my surprise (well, maybe not) MAMSI denied my coverage yesterday for a one-level ADR at L5-S1, stating that it's "unproven/experimental." They apparently have chosen to ignore the OPM regulation that clearly states that for Federal Employee Health Benefit plans, any FDA-approved drug, device or product cannot be deemed "experimental" or "investigational".

The appeal is already written and will be in the mail tomorrow. The appeal basically says that the FDA has approved Charite ADR, they're obligated to cover all FDA-approved procedures, so they either approve it or incur the wrath of the Federal Government for violating OPM regulations.

I really sympathize with those of you that are at the mercy of the insurance providers and that don't have any recourse for independent appeal...

-stan

paulam310 05-11-2005 10:09 PM

Good for you Stan! FDA approval of the charite puts it out of the experimental category. Keep going till you get it.

JoJo 05-12-2005 06:03 AM

I am at the external appeal phase myself. My appeal goes to the Insurance Department of my state. (NY) I'm faxing it today.

It's all just a delaying tactic. If they can put us off, some of us will die before they have to pay.

Good luck with your appeal!

NCFUSED 05-12-2005 11:58 AM

I went thru 3 appeals and got a NO at each level, all taking over the posted amount of time
(15 days posted, 30-45+ actual for each appeal) in each letter UHC / my employer sent.

I have fusion of L5-S1 scheduled for this coming tuesday.

My Doctor did say the Orthopedic Specialist for UHC called him to discuss my case in the 2nd appeal phase, My doctor said that their Doctor had obviously been retired and out of the Mainstream for about 10 years, and already had an implanted NO in his head even before discusing ADR with him. For Every 10 good points they discussed the "specialist" just focused on the 1 negative point.

Oh well, Wish me luck.... I wish all of you the best in fighting the good cause.....

Harrison 05-12-2005 07:14 PM

Knock em dead, Stan! Or at least bowl them over with your eloquent, persuasive and governent-backed ammunition!

http://adrsupport.org/groupee_common.../icon_razz.gif

Kim 05-13-2005 11:48 PM

Good luck and my best wishes to you! Prayers going up for a quick approval for you and go get em!


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