My pain management dr, scheduled me for some injections next week and the insurance denied coverage. When he scheduled these I had forgotten that last year they denied coverage as well so we went ahead and paid cash well i cant afford to and now what? first they deny adr surgery saying it isnt medically necessary and now they are saying the injections are not medically necessary. I am at my ropes end, what is the point in having insurance if they wont help me. I am ready to start filling my scrips for the patches and morphine they had me on, not take them just get them and make themn pay for all of it. I am in so much pain. Is this common? (insurance denial that is)

Julaine

--------------------
Back pain 10 years +
Chiropractic care 1993-1994
DX 2003 DDD at L4 5 S 1
January 04-Nov 04 Epi Injections
October 04- March 05 Morphine, vicodin, Duragesic,
Since March Drug free.
June:Now on Ultram
Blue cross denied my two level ADR.

Julaine

This is an atrocity how can they deny an injection for medication and give you a patch of morphine to get you addicted to medication. Are you doctors coding everything correctly? What is the diagnosis they are using? What are the codes? I had 2 injection earlier this year and will ask what the code and diagnosis was? I will be by the office today and will ask for you. This is absolutely appalling in my eye http://adrsupport.org/groupee_common...s/icon_eek.gif and you should fight this!

I'm v. sorry to hear this. Dr. Kropf - Delamarter's partner - told me that BC in CA will be the last holdout on paying for ADR's. I don't know why.

I am fed up with everything. I spoke with the surgery center and they called insurance and BC now says they are covering the procedure and I dont need pre authorization. The lady on the phone also told me that i dont need pre authorization for any procedure including surgery. which doesnt make sense to me. I have Blue Cross EPO, which is basically a PPO. Has anyone ever heard of this? Not needing authorization for a surgery.. if that is the case then heck sign me up!

Julaine

I would suggest you file an appeal to their denial of the injections following the insurance companies procedures that are probably stated in your handbook. I wouldn't let them get away with not paying for treatment you have already paid cash for.If the appeal doesn't reverse their decision then you can file with the appropriate agency outside of the insurance company. My experience is that it sure works better to file in writing than just having the doctor's office call. It's ridiculous to pay premiums to insurance and then be denied. I hope you can change their decision.

Julianne
Not needing any preauthorizations sound fishy to me and believe me I would want something in writing stating they were payiing for any expensive procedure cause bottom line is you are responsible if the insurance company does not pay in most cases and most of us cant afford out of pocket expenses in the 10s of thousands of dollars. If you notice when you call your insurance carrier for any info you always get that lovely recording stating that anything they tell you can change so my policy is get it in writing or I dont depend on it

J - When you're dealing with issues this important it's always a good idea to get the complete name and position of the person providing the information. At the very least you then have either corroboration or someone to point a finger at when you receive conflicting information from some other source. Kim's absolutely on the mark; get it in writing!!!

As to the details of authorization, each BC issues a Member Handbook (which is *not* the contract) which spells out most details. Also important to obtain and read through thoroughly is the Benefit Description (which *is* your formal contract). You probably will have to ask your plan sponsor or employer (or whoever you get your insurance through) to provide a copy of the Benefit Description, which is the legal document that describes your coverage. The details in the Description are more extensive and need to be read and understood because they are the final, definitive answer as to what services are provided (or not).

Speculation here, but I wonder if the BC authorization for the procedure that Julaine mentioned might not be the change we've been expecting as of July 1, i.e., the new procedure approval codes. Prior to yesterday there were no approval codes for ADR and surgeons' offices were using other codes to enable these procedures. Of course it could just as likely be simply some dimwit in the doctor's office thinking about some other insurer's policy or something equally as mundane.

Julaine, I have Blue Cross PPO and my insurance covered all of my injections and surgeries. Hope this bit of info might be helpful.

My BCBS PPO in CA covered all of my injections. I could not get a straight answer from Utilization Review if they cover ADR.

J

Sorry I forgot to mention this in my previous post, but the two posts above this one confirm it, i.e., I think the denial of pain meds was a mistake, pure and simple. I'm pretty certain if you contact someone else at BC you'll find it was simply someone's error. This happens all the time.