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-   -   BCBS of NEW YORK DENIED (https://www.adrsupport.org/forums/showthread.php?t=13650)

ouchtear 03-06-2017 10:57 PM

BCBS of NEW YORK DENIED
 
After months and months of internal appeals and finally a external appeal from New York state it was finally denied. I was going to have a one level l5-s1 done with either a Prodisc L or Activ L at the Texas Back institute. It's such bull****.. No evidence to support it is better than fusion... Then with that logic there is NO evidence to support that it is worse. So then let me chose then... I guess I am at square 1 again.. I may just take a gamble and pay for it out of pocket somewhere...submit it and then fight them like hell to pay for it..

Nestletea 03-08-2017 10:41 AM

Texas Back Institute
 
Texas back institute will do an all inclusive package - $36,000. However, this does not include hotels and transportation. I had the same insurance issues with BCBS and went through the appeals process. I have decided on Barcelona Spine Center and have surgery scheduled on March 15th at the L5/S1 level utilizing the M6L. The total cost including hotel and transportation is $30,000.

Best of Luck!

Leanne

ouchtear 03-09-2017 09:45 PM

Thanks, Yes I know about Texas Back Institute that is where I actually went. I have also had a quote from Doctor Clavel too. I would need a loan and there really are no long term loans out there for this that I can find.. there are 5 year loans.. but I would need around 10. I wish you the best with your ADR. The euro has dropped quite a bit to the dollar so that is good right now.

LumbarSpine 05-10-2017 02:21 AM

I would argue that there IS evidence that ADR is better than fusion. I can't speak to your specific case, but in general, ADR is motion preserving, and reduces by a lot (I believe the study I read said over 3X) the chances that you will have adjacent segment problems. I feel like this is a case of knowing what literature is available to support your arguments. Perhaps you already know and they are ignoring it, but if not, keep in mind that there certainly are studies that show ADR is superior to fusion. If I recall correctly, some studies mention faster recovery also.

ouchtear 05-15-2017 10:02 AM

Yes.. That is the evidence that I agree with too. It was 3 independent Doctors in New York State that make the final decision on the External appeal. 3 morons if you ask me.. If they are not morons then it has to be only one thing.. a conspiracy to make a lot of money at not actually fixing the problem.. Drug-surgery-drug more-surgery more etc....etc...Just think of the billions of dollars every year spent on spinal injections alone.

ia75 10-14-2017 08:31 PM

I agree! The BCBS FEP "expert" who denied my appeal is Dr Santamaris and specializes in hospice/palliative care. I never even had a chance, what a Scharade this appeals process is :( Not sure if switching to another insurance would have a better outcome...

GKTM300 10-16-2017 12:38 PM

Well
 
If you do your research n appeal it with a good argument I don't seek how they can't pay. Also I was told fusion ain't so bad if done correctly. I was told the hardware is suppose to be temporary and that the pad and two pedicles are fused and hardware taken out a year later.

pittpete 10-16-2017 07:34 PM

I had L4-S1 fused 2+ years ago.. I'm doing 100x better than presurgery.
No reason to remove hardware if it isnt causing issues.

GKTM300 10-23-2017 11:27 AM

Lawyer
 
There's a lawyer in San Fran I think he is listed on a Adr dr web site. He has been fighting n winning these cases for people w bcbs federal amount others I think he gets 10 percent. I haven't spoken w him I made a deal w myself if it worked I didn't mind paying

Harrison 11-14-2017 12:28 PM

Contact Laurie:

http://www.theinsurancewarrior.com/

She's better than a lawyer and more effective. I've not spoken with her for years; I hope she's still in the business!


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