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-   -   Good Insurance Co. News! (https://www.adrsupport.org/forums/showthread.php?t=9125)

letteski 11-04-2005 02:29 PM

Hi All,

With all the bad new re: Insurance Companies these days I though I would share with you some good news! My insurance "Health Comp" has paid 100% (-deductibles) for my 1 level ADR-ProDisc.

Not sure why they change there mind, they said before surgery that they would only pay for the surgery and not the ProDisc or any complications caused by the ProDisc in the future because it was not FDA approved. This information was presented to me in a letter. As some may remember this was a very stressful time for me and after 3 attorneys showed me the door, I found one and 3 days before surgery he helped me write a letter in response for the fee of...... "ProDisc Study Articles I have from Dr D and a phone call 1 month post-op". What a deal!!!!!!!!

I would like to share with you the "friendly letter" I wrote to my insurance company w/counsel help. It was sent on the day of surgery certified along with a letter of Medical Necessity from Dr D and 4 Study Journal Articles.

Those of you in the fight of your life please feel free to take anything from this letter that my help your fight. There is some legal �mumbo-jumbo� that may have gotten my IC to reconsider. They never responded to the letter, just paid all the bills. I hope this helps others get there life back as well.

Health Comp
Claims Department:

I received the letter you sent on August 12, 2005 regarding coverage for Spinal Surgery with Artificial Disc Replacement.

I have enclosed a letter of Medical Necessity from Dr Delamarter supporting the authorization made by Universal Health Review on July 26, 2005. This explains my decision of medical necessity to have Artificial Disc Replacement surgery with the ProDisc and not the LINK-Charite prosthesis to prevent future medical complication.

I have provided 4 published reports and articles from medical and scientific journals and literature deemed to be authoritative within the professional medical community in the United States supporting the safety and efficacy as compared with standard means of treatments or diagnoses.

Your stated reason, �It has been established the Spinal Surgery with Artificial Disc Replacement (ProDisc) has not been FDA approved and therefore is not a reimbursable expense under the Plan provisions,� appears to be �circular� reasoning. First, someone from the plan must find that the device is experimental, investigational or done primarily for research. Has this been done? If not, insurance should cover the operation and its aftermath. If so please answer the following questions.

Is it your, (the plan) position that the device is experimental? If so please specifically state all your reasons for such a determination. Please state all names and contact information for the person/persons who made that determination, their qualifications and the specific evidence and documentation they relied upon in making that determination. (Give cites to or send to me all documents relied upon). Also include when the information was reviewed.

Is your (the plan) position that installation of the device is investigational? If so please specifically state all of your reasons for such a determination. Please state the name and contact address of the person/persons who made that determination, their qualifications, and the specific evidence and documentation they relied upon in making that determination. (Give cites to or send to me all the documents relied upon). Also include when the information was reviewed.

Is it you, (the plan) position that the device is primarily for research? If so please specifically state all of your reasons for such a determination. Please state names and the contact address of the person/persons who made that determination, their qualifications and the specific evidence and documentation they relied upon in making that determination. (Give cites to or send to me all documents relied upon). Also include when the information was reviewed.

Your letter has caused me a great deal of anguish. I don�t feel that you investigated the device at all and are using the FDA approval process in a manner not contemplated in the insurance document to deny me coverage. You have forced me into a position of having to decide to live in constant pain, and continue to be completely disabled from work, or to accept a universally recognized device that in my Doctors opinion, is not even appropriate to my condition but which you will pay for, or to proceed with no coverage for complications if I use a device which all the scientific literature states is superior and all involved doctors agree is superior for my condition and which has been used over 10,000 times worldwide.

I cannot stand the pain any longer. Putting in an inappropriate device is just stupid and harmful. In my doctor�s opinion, waiting may cause more nerve damage further causing longer delays in my return to work or permanent disability. After consultation with my doctors I have decided to have this operation and have it now because my medical condition demands it. This is the number one disc in use, worldwide! In my opinion as my insurance you, (the plan) should agree to cover this device. This is the best and most necessary medical decision for my immediate future health.

Good luck to all of you in your fight for a pain free life.

God Bless

luvmysibe 11-04-2005 02:52 PM

Yeah! With all of the negative news and ill feelings regarding insurance companies this is a positive rarity. Hopefully, this will help others in the approval process.

Thanks a bunch!

JeffreyD 11-04-2005 03:29 PM

Nice approach! Congratulations on the coverage of bills!
.....are there 10,000 ProDiscs installed in folks worldwide?.....is the Podisc the number one disc in use, worldwide?
I've never heard this before.

Jeff

letteski 11-04-2005 04:08 PM

Jeff,

This was a quote from the letter Dr Delamarter wrote for me re: Medical Necessity. He will have to answer to these claims himself. But I am aware that he has consulted with Dr B on their ProDisc patients just recently in Europe. He would know better then I and would not put past a little exaggeration from the cowboy. http://adrsupport.org/groupee_common...icon_smile.gif

Kim 11-04-2005 07:35 PM

WTG Paulette!!!!
Always nice to hear good news hun

Harrison 11-05-2005 09:15 AM

Nice job Paulette, thanks for sharing this. Now you can spend that $ on important things, like skiing, new mountain bikes... http://adrsupport.org/groupee_common.../icon_razz.gif

11-06-2005 03:06 AM

Bravo Paulette! I'm new here and have read many of your posts and your detailing of your surgery with Dr. D. I had a discectomy by him last year.

You obvioiusly are very tenacious and I greatly admire your persistence. You are very inspirational, and your sharing of your "proven" letter, and surgery is great. I saw your picture in front of the Venice?? boardwalk. I'm so happy to read your story, see your picture and hope that you continue to have great success!

I am trying to get an ADR but Medicare is not paying enough for the hospitals here to book these surgeries. I will write a letter to Medicare and may use some of your wording if that is OK?

Thanks again!
Best wishes!

11-06-2005 02:30 PM

Only if All Insurance Companies would pay for AR's then there might be less suffering!!!


sessler
1999 Microdestomy L4-S1-Failed
L3/L4 Buldge Big
L4/L5 Half disc left
L5/S1 ADR Keniflex July 18, 2005

11-06-2005 07:04 PM

Good Job Paulette,

I think you were successful in getting your ADR paid for because you were able to put the bill in their court, and they had no legal reason not to pay your legitimate claim. All who are fighting with their insurance co. for authorization should consider this path. The ins. companies can say no all day long and as long as you listen to them and do not proceed with the surgery you and your Dr's think is a medical necessity then they win.

Read your policies and how many days planned stay in the hospital are required before pre-authorization is needed. It is usually 3 or more days. Plan your surgery and get out in 2 days and move to a hotel near buy till your first follow up. All Paulette's letters did not hurt her case, but everyone has a legal contract with their ins. co. and if you follow the terms they must also as well. This is an FDA approved procedure. It is not investigational any more as far as our Government is concerned. It does not matter if your insurance co. still think it is still unproven. If they don't pay quickly then you will have a real claim and damages that are provable. It now becomes a matter of contract law and the law is now on your side.

I hope your recovery continues to go well Paulette. Take care,

Pat

letteski 11-06-2005 11:11 PM

Pat,

Very well said thank you. http://adrsupport.org/groupee_common.../icon_wink.gif I just don�t know why Insurance Companies have to make the pre-cert. posses such a nightmare. We are in enough pain as it is. What they say and what happens don�t match-up.

I was told by the pre-cert level this was not a PPO hospital or Doctor. When the EOB came the Hospital gave the Insurance Company a �Pro-Net Discount� a $31,000.00 Discount. Something is going on behind the seen that I�m not privie to as the patient and will just say out of this one. Just glad I got this discount. Why can�t Medical patents get this too I�m sure they could afford $6,000 for a 1 level ADR. Hmmmm......

I will pay my deductible and smile all the way to the Post Office. http://adrsupport.org/groupee_common...on_biggrin.gif

Freshfig,

Thanks for you kind words I�m glad my story is encouraging you. You can take anything you like form the letter. Welcome to the forum and I hope you find it cozy here I did. http://adrsupport.org/groupee_common...icon_smile.gif

11-07-2005 05:20 PM

Puelette,
Thank you for your kind welcome. I have found the people here to be very welcoming and more than willing to help. Thank you for your offer to let me use parts of your letter!

Pat,
I have found that Medicare will pay for the surgery but the amount they are willing to reimburse is less than what the hospitals will accept, especially for the disc itself. This seems to be a big sticking point. Do you have any suggestions how to overcome or get around this? Any thoughts would be greatly appreciated.

Thanks!

11-07-2005 05:24 PM

Paulette,
Sorry about spelling your name wrong! I can't seem to figure out how to fix it.

11-07-2005 05:52 PM

Paulette,
I hope you don't mind another question?

Were the articles that you sent with your letter "4 published reports and articles from medical and scientific journals and literature..." provided by Dr. D. or did you find these on your own? I have articles that were provided to me by Depuy Spine. Can you share what articles you provided?
Thanks !

letteski 11-07-2005 11:49 PM

Freshfig,

Yes these were 4 published reports and articles from medical and scientific journals and literature provided to me by Dr. D research department. 2 from Dr D, 1 from Dr Zigler and the other a 10 year old study all on the Prodisc. I can�t post them because they are on PFD but if you PM me your email I can email them to you.

No worries about the spelling I am know around here for my creative spelling. What are you doing on Sat? I will be in LA and we are having a gathering in Marina Del Ray for anyone from the forum that wants to connect with other spinies. You can read more here Hope you can make it. http://adrsupport.org/groupee_common...icon_smile.gif

One way to get around the cost of the disc is to get involved in a study the disc is paid for by the study. I would call Dr D�s and see if they have any study�s opening in the near future. The Prodisc vs ActivL sounds real interesting.

11-08-2005 06:10 AM

Freshfig,

All I can say to your Medicare question is to keep asking questions and get the names of the people who answer them and try to record your phone calls with them to document their responses. You need to inform them that you are recording the call to keep it legal for your protection. If they won't agree to the recording then just try to document response in writing as they give it. You are now in a negotiation to force two entities to live up to their contractual agreement with you and each other. You are close to getting it done it is just a matter of the bottom line cost for everyone.

First find out if your Dr. and hospital has a contract with Medicare and accepts other Medicare patients. Some do, some don't. If they do have a contract with Medicare ask them why they won't accept Medicare's figures and then contact a Medicare lawyer as to your legal rights to force the hospital to live up to their contract with Medicare. I would guess that if they have a contract with Medicare then they have one with you by default.

If your Dr. and hospital don't have a contract with Medicare ask Medicare why the reimbursement is so low for this surgery? Ask them how they determine what their reimbursements rates will be for any surgery and where in your Medicare contract does it spell this out in writing. Ask them what hospital and qualified Dr. do they have available that will accept their figures to do this surgery. Try to back them into a corner where their answers will trip them up.

At the same time you are working on Medicare ask your Dr. and hospital how far a part the Medicare reimbursement rate is from what they will do it for. Ask them if you can make up the difference. Once you got the figure then ask them what kind of payment plan will they accept to help you out with this. If you can get the hospital and Dr. to agree to do it with out you paying all the difference up front then go for it and worry about how you will pay for it later. Unpaid medical bills will not impact your credit as other bad debts do, and as long as you can make some kind of regular payment to the hospital they will wait for it.

Your goal here is to get fixed so you can get back to living a normal and productive life. I must also say that only you and your Dr. know your medical situation. I assume that you both agree that ADR is the best course of action for getting you better. There are risks to this surgery and you have to be prepared to deal with a less them optimum outcome. Your pain and quality of life should be so bad that anything will be better then what you are living with today.

Good luck with it. You are close and persistence does pay off

Pat

11-11-2005 04:00 PM

Paulette,
Thanks, I will PM you and give you my e-mail address. If you can send the articles that would be a great help!

Where can I find the address for the BBQ this Sat.? I would like to come but this past Wed. I had a shot in my butt and the woman hit my sciatic nerve, even though I warned her to keep away from that area. She assured me that she was aware of the pain, as she had been attacked by a dog and has herniated disks from that attack.

Needless to say the next day I was in excruciating pain from her hitting that nerve. This is the third time this has happened. No more shots in the butt!

If I can walk by tomorrow I would like to come. Can you e-mail the address with the articles?

Thank you so much for your help!

BRENDAWY 11-11-2005 07:49 PM

Paulette, I am so happy for you. This instills hope in us all. That was a very clever way to go about your appeal. I will be using some of it for my next letter. I am still going to Germany, but would like my insurance to reimburse me. Congratulations! BrendaWY

CindyLou 03-12-2007 02:05 PM

I'm wondering, Paulette, or anyone out there, really. Could you email me those four published reports and articles from medical and scientific journals and literature deemed to be authoritative within the medical community? I would really appreciate it. I'd like to add that with my cover letter to my appeal with HealthPartners. Thank-you, thank-you Cindylou

Harrison 03-12-2007 02:57 PM

CindyLou (and others),

If people want to help you by sending you the articles you requested, you need to have your email visible in your public profile:

GO > Personal Zone > Profile > Edit

CindyLou 03-12-2007 04:14 PM

Harrison,
I think my email is visible. Someone sent me a private email message yesterday, so should I assume I am all systems go? You can tell I am not that techy savy!

Abbe 03-21-2007 09:18 PM

Boy couldn't we all use some good news! I am on my second denial and if that weren't all I have decided to go back to Dr. Delamarter and stop going to Dr. Williams. I had asked Dr. Williams how many disc replacements he had done and he told me 15. That was too few in my mind. In addition his office never seems to get back to you so I had to make an appointment and go see him just to discuss being denied and what our next plan of attack should be. He had no idea that I had been denied the first time because he was never given my file to write to the insurance company. The gal who schedules the surgeries just sent in to the insurance co. and never got a letter of necessity from him. Then it was submitted incorrectly anyway. http://adrsupport.org/groupee_common...s/icon_mad.gif So, now that I am educating myself on this whole process I have found that Prodisc has an advocacy program for patients and they will work on your behalf to try and get the insurance company to approve the procedure. You can go onto Prodisc's web sight and get the phone number and contact them. They will need to be able to get your medical records so they can act as your agent so to speak but they have been very helpful and as with anything you have to be persistant. I did find out today that my insurance Co. asked for some more documentation so, I guess that this is better than another denial. My plan "C" is to use a version of the letter Paulette posted here and I am asking for the articles she mentions as well.

Abbe

letteski 03-22-2007 08:44 PM

CindyLou and Abbe

ProDisc Study Articles and more ADR Articles you can find on David's Blog under Study Articles.

Harrison any chance some of these can make there way to a special link on ADR Support so they can be found easyer by the community?

The best advice I can give you is to never give up and keep breaking the IC down. Please use any part of this letter you need. When it comes to dealing with Doctors offices don’t expect them to call you back, if you what to see them or have surgery with a particular doctor you have to foster all the communication. The office staff is under paid over worked and they don’t have an ounce of sympathy for you. Your just another phone call they have to deal with.

I hope this helps and don't hesitate to PM me anytime. Life is great and I'm here for you http://adrsupport.org/groupee_common...icon_smile.gif

CindyLou 03-23-2007 06:08 AM

Paulette, thank-you for the information. I'd like to PM you with some questions but am not sure how to do it at the moment. I am a big skier as well, certified instructor, and one of my questions is: will I be ready to ski next January after having my adr (3 lumbar levels) in April? That's about a 9 month rehab time table. I stumbled on to your website and it makes me very hopeful, altho I know 3 levels is major. Did you have 1 level or more? Please, if you see this, maybe you could PM me with your email address. Thanks.

letteski 03-23-2007 08:00 AM

Cindylou

I sent you a PM so look for it. So you can learn this function. Let me know if you can't figure it out I will check back.

Abbe 03-23-2007 08:17 AM

Paulette,
I think you meant to PM Cindylou and somehow I got your PM.

Abbe

CindyLou 03-23-2007 08:24 AM

Yes, I know how to receive the PM, just not send one! Not too tech savvy. But I did receive yours and thanks. I'm hoping and praying that when Dr. B gets in there, he will go, oh, not so bad, only 1 adr is needed. But that's not very realistic as my discogram was concordant pain 10/10 at L3-4, L4-5, L5-6 (my extra vertebra). This distraction pain is scaring the hell out of me. It's hard to think of being limited and in enough pain now, only to go into more extreme pain after surgery, and then to hear from some dumb *** that her adr didn't help at all. I did not need to hear that from her. I am at the end of my rope, yes, but I am diving into adr with all the hope in the world that this will help me! Sorry, I just had to rant/rave for a minute. Some people can be so stupid. I'm in really decent shape going into this, not overweight at all, eat right, still make myself get on treadmill with pain, so I'm hoping those factors will help with recovery. How long approx does the distraction pain go on? Or is it all over the board? That's enough rambling on my part. Off to the bank to wire the money for surgery. Thanks again! Cindy

Abbe 03-23-2007 11:28 AM

Cindy Lou,

I think you meant this PM to go to Paulette. I have not had ADR done yet but it sounds like you and I have the same levels that have gone bad. I have L5, S1 partially sacralized. On all my previous MRI's that is how they classified it but on the most recent one the radiologist called it L6, S1. Partially sacralized means that it is partially fused to the sacrum yet partially free as though it were an extra vertebra and degenerating in the disc area. L4, L5 I have had a hemilaminectomy and discectomy and I am now bone on bone with virtually no disc left at all and what they call ostiophites which are bone growths from the vertebra going outward trying to compensate for the lack of disc. These growths and impinging on the nerve. At L3, L4 the disc is ruptured and torn. Back in 2004 Dr. Delamarter wanted me as part of the Prodisc trials and he was going to do a 2 level replacement but he was supposed to write to the FDA for a compassionate use waiver since I had already had back surgery. Well, I kept calling to see if it was sent and the person who was supposed to get that letter sent out left and another person took over. I kept calling back and no one would return my calls so I got lost in the shuffle. I also was not 100% sure I wanted to be in a study and thought I would wait for FDA approval.

I went to a neurosurgeon that my plan referred me to and he wanted to fuse L4, L5 and do a disc replacement at L3, L4 but then moved to Baltimore. So, Then I went to Dr. Williams and he is the one that wanted to do 2 fusions and a 1-disc replacement only because it is only FDA approved for one level. I am wondering how people are having multiple levels done here in the states. My guess is that they are paying out of pocket.

Abbe

Terry 03-23-2007 04:56 PM

CindyLou:

Like you, I have been very athletic even before I went to Germany for my surgery. I had bicycled near 2,000 miles and did an incredible amount of walking pre-surgery. I went in to surgery at 163 lbs and 10% body fat. The better condition you are in the better your surgery and recovery is going to go.

I had 4 level ADR and was very compressed and re-gained 1" height out of the deal and have had a lot of distraction pain. I am on Lyrica 400 mg per day to deal with nerve pain and would still go through it again in a heart beat. I am much different today than before surgery where I walked with a cane and was bent low to the ground pre-surgery. I stand upright and my posture is amazing today.

I do not know how long I am going to have to deal with the distraction pain but am eager to be on my bicycle and am scheduled for my first ride of the season tomorrow.

Trust God, the homework you have done before surgery, and the care givers there and at home afterwards. You'll remember the pain pre-surgery and realize that you can live with the aftermath as long as the surgeon does a good job. You're heading to a good place and all of the worrying will not make it any better.

Take 5 deep breaths and call us in the morning.

Terry Newton

CindyLou 03-23-2007 09:38 PM

Thank-you Terry. I needed to hear that.

desert brat 03-27-2007 08:09 AM

Paulette,
Thank you for sharing. I just postphoned my c5-6 & c6-7 cos my Dr wants to do anterior fusion instead of adr only cos the ins won't cover it. I am in the Atlanta Ga area. Ihave been reading & looking everywhere for more info on Dr. that will do this surgery as well as can help me with insurance.so far no luck.I am to the point I just may go ahead & get fused just for some releif.Is there anyway I can also get copies of those articles? Again THANK YOU SO MUCH & May God Bless. DesertBrat

CindyLou 03-27-2007 08:52 AM

Desertbrat, I'm sorry. You sent your PM to Cindylou instead of Paulette. Try again. If she doesn't respond, I know she was going to Hawaii for spring break, but she'll get back to you. Take care! Cindy

desert brat 03-27-2007 09:23 AM

Sorry bout that I am not very good at this kind of stuff! Thanks

desert brat 03-27-2007 09:27 AM

Paulette,
Hope I have it right this time!! I sent it to Cindy Lou last time. Is there anyway I could get a copy of those reports as well I think I just may need all the help I can get with my Ins companies.Great news for you Im truly happy for you May God Bless

CindyLou 03-27-2007 11:21 AM

Sorry Desertbrat, you sent it to me, Cindylou again! I wish I could help you, but I'm not too good either with this stuff! Cindylou

Abbe 03-27-2007 02:59 PM

Abbe Here,
Go to the forum
http://adrsupport.org/eve/forums?a=frm&f=7701036081
Find Letteski and click on her underlined name. She did post that link. Here it is for the articles: http://adrsupport.org/eve/forums?a=frm&f=7701036081

Hope this helps.

Abbe

Abbe 03-27-2007 03:04 PM

Ops! Here is where you can find the Articles:
http://www.dhwaldron.net/adr/pdf/

desert brat 03-28-2007 07:19 AM

Abbe, Thanks for the info & address. I just have to call & get a procedured code to give to my ins. to see if I will be covered

CindyLou 03-28-2007 08:26 AM

Desertbrat, I'm not sure why or how, but I am still receiving your PM's intended for Abbe. Then she responds and they come to me, but are intended for you! Hope you can fix this. Cindylou http://adrsupport.org/groupee_common...icon_frown.gif


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