This is a good topic with some real informative posts. I have learned alot that may be useful in the near future. Oddly enough, my first ADR in Feb 2004 went through with no problem - fully covered. I still haven't figured that one out, but I believe it was in part because at that time there was no code for ADR. But anyhow, since then Health America Insurance has been denying coverage for everything they possibly can for me and taking their good old time with every step. So, If I end up needing the additional 2 level ADR, I am sure it is a hopeless battle with this insurance company especially, or any other, most likely.

They rejected my surgeon's pre auth request for the Nucleoplasty procedure that I am having on Thursday. When we appealed it, they said they had 4 weeks to decide, but that it usually only took 2. Well, my doctor had to call them after 6 weeks and they claimed it had been reviewed, just not decided on. I thought we had a good and informative argument too. An hour later they called to say it had been denied. I would love to see these documents you talk about, as I don't think anyone looked at it before that day when it was denied. I don't think mine was supposed to be an Independent Review though. ?? I think it just went in front of their medical review board. I am not sure. I need to learn more about this, that is for sure!!!

Good luck to you Big Red. It sounds like you really know alot about these insurance processes. Are you in the medical or insurance field yourself?? Or self taught for survival?

I have a question - off topic - both Eddie and Chuck mentioned the trial with Dr. Yue and saving $$$. May I ask why? Is some or all of the costs of this trial covered?? Just curious. I have considered seeing Dr. Yue before I take the big step and go to Germany (my next step if this nucleoplasty doesn't work). I imagine I wouldn't be a candidate for Yue's trial or any other trial though.

Well, good luck to all.

Go Big Red,
I wish I had some good advice for you. I think of you often and feel it's a shame that you are still dealing with this. I am quite sure your surgeon (and mine) will be very competent in the phone interview, as will you. If you feel the need to vent, let me know. Meanwhile, keep plugging away.

Hi, Mars

Nicole called me yesterday and Dr. P is in surgery all day that day and 1:00 is right in the middle of a big one. When she told me that, I just lost it. I can't believe how emotional I am! But, when he gets back into town today she's going to speak to him about it anyway. And, the rep for Charite' has done this many a time and is willing to phone interview with me or even go in person.

So, I'm going to check today and see if the interview is in Denver. If it is, then off I go in person. It's just so scarey. I hate my life being held in the balance by a dr. I don't even know and doesn't know me.

You know, we deal with the pain and crap for so long that looking at us it's hard to believe we are in constant pain, you know?

Anyway - may give you a call. Thanks. How is your recovery going? Like the surgery and injury never happened, I hope.

Well, so the saga continues. It wouldn't matter if Dr. P. was available at that time or not as they do not allow the doctors in on the call. So, the Charte' rep was going to sit in, but they won't allow that either. *Sigh, sigh*

So, that means that I'm on my own. The rep told me to not be intimidated which happens, maybe not intentially (yeah, right) but it happens often. Oh, and get this. Nicole and I had decided to by-pass the internal review and go for the external independent review instead. PC disregarded that request which was clearly stated in the letter that we could choose either. So, in total disregard to my wishes using THEIR protocol, this is an internal review. Which means, to my understanding, that there will be YET AGAIN a bunch of suits deciding on MY life.

How can they do that? They don't even know me! They don't know what my life is like. They don't know anything nor do they care~~~~~

I am sorry but not surprised that you are having to go through this. You are in an adversarial situation.
A couple of additional thoughts:
(1) check to see if Colorado statutes allow you to file a complaint to the Medical Board against a physician who does an "independent medical exam/review." Unfortunately for me, Arizona law does not permit this, which means that physicians here who do IME's can lie, commit perjury, prostitute themselves for insurance companies and yet are totally untouchable.
(2)There is a certification board for IME doctors which has a code of ethics to which they must subscribe. When asking this doc for his credentials, also inquire whether he is certified by this board.

Wishing you all the best.