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-   -   Anyone get a state agency to overturn the ins co? (https://www.adrsupport.org/forums/showthread.php?t=7879)

mmarsh 05-06-2008 04:30 PM

If anyone has had success in getting a state agency to overturn their ins co, I'd surely like to see what you have. BS of CA has denied me again and so now I'm off to the Dept of Ins, state of CA. Any helpful hints would be appreciated. Having trouble finding cervical studies, especially peer to peer reviews. Anybody got anything? Thanks in advance.

Missy

mdm798@aol.com

FIXITRIGHT 05-19-2008 10:22 AM

I just won an appeal on Oklahoma Workers Compensation, (Comp Source) on a two level cervical adr C-5,6,7. Let me start with my history. I had a car crash in 2004 which led to fusions at C-3,4,5. Another crash in 2007 which messed up C-5,6,7. Fusion approved but I didn't want my entire neck fused. My Neurosurgeon said that I needed a two level adr to return to work but he could only do one level. He referred me to Dr. Zigler at the Texas Back Institute but Worker's Comp. refused the referral to get an opinion whether adr was feasable or not and they said they would never approve adr surgery. I went on my own dime to TBI to see Dr. Zigler and he said I was a good candidate and it would offer me the best chance to return to work. I got the recommendations from the two Neurosurgeons and my attorney and went to court. The Judge agreed with the Neurosurgeons and advised that as long as they agree to comply with Oklahoma Worker's Compensation pay schedule and the Certified Workplace Medical Plan then I was approved for surgery. I went into this letting the doctor know what I was up against and what I needed to get it. He had some experience with Worker's Compensation and wrote the letter and addressed it to Dr. Hisey, (my Neurosurgeon that is Worker's Comp. approved,) in Oklahoma to get it into the system so that it would be in my medical file and recognized as part.

Terry 05-19-2008 05:56 PM

Congratulations. It sounds like you can get it FIXEDRIGHT and move on with your life. Had to play on your signature. Sometimes you eat the bear; sometimes the bear eats you. This time it sounds like you ate the bear. I hope everything comes out OK for you now and let's hope others have the same success. We have such an inequitable health care system in this country. Some are covered, some are not and there is no rhyme or reason.

Again, Congratulations. http://adrsupport.org/groupee_common...on_biggrin.gif

Terry Newton

CindyLou 05-19-2008 06:07 PM

Congratulations FIXITRIGHT! Good for you for fighting the good fight, and not giving up. And I tip my hat to that judge as well. Maybe you should contact your local paper, to see if they would be interested in your story, as a human interest piece. And it would be some good PR for adr as well. Good luck as you face your surgery, and all the best to you.

mmarsh 05-19-2008 07:04 PM

Congrats to you fixitright! I hope I get someone who has the ability to think at the state agency. It seems so simple to me that a procedure that costs over $50K less and has a very positive outcome is being overlooked because the ins co policy says to deny ADR! Is there anyone working for the ins co that is paid to think? I'm not sure because every person I asked to please explain this to me said that it's not their job! Is it anyone's job? Holy smokes! If it's cheaper and better what are they waiting for?

Missy

Terry 05-20-2008 03:31 AM

They don't care about your health as their real mission is to save money and report to shareholders. That is the true essence of our health care system and why it leads to discrimination and inequity in payment and reasoning. If health care became mandated to some level with a degree of accountability on people for taking care of their own health (A reward system if you will for people making healthy lifestyle choices based on good, sound, educational, and prevention focused health care) we would have a system that would work for the people instead of for the profit mongers. Now wouldn't that be lovely.

Terry Newton

CindyLou 05-20-2008 05:13 AM

Amen to that Terry. Our healthcare system is a complete embarrassment, being the wealthiest country in the world.

FIXITRIGHT 05-20-2008 07:18 AM

I don't want to get too optomistic because they could appeal the decision but, I don't think they will. I also said it wrong. They said no and I took it to court so, it actually was not on an appeal however; that makes it a better win by not having to appeal a court decision. I merely challenged their no. Still working on getting surgery scheduled. I hope that this will help all of those that come after me.

LBP 05-20-2008 11:06 AM

Missy,

Sorry to put a damper on things but Ca Dept of Ins upheld Pacificare's denial of my 2 level Charite ADR surgery request. Then I requested another review for a hybrid (charite/fusion) and when Pacificare/UHC denied that too, the CA Dept of Ins wouldn't even look at the appeal because they said it was the same as my initial request. That was a few years ago, maybe it's better now.

mmarsh 05-20-2008 11:47 AM

Other than my spine, I'm the healthiest 51 year old I know! I walk at least 2 miles every day, work out for 1 1/2 hours 3 days a week, play golf 1-2 a week (All of this when healthy, now I'm only walking), so Terry's idea of a payoff for good behavior is okay by me! I don't have high blood pressure, high cholesterol or any other health issues, just an old spine! Wish they would look at the big picture for a change and reward those of us who are not bleeding them dry! LBP- I hope the state agency has changed as well. Since they don't have to put their results online like the Dept of Managed Health, I don't know if anyone has been successful at appealing the decision of the ins co for ADR. I'm hoping that the dissertation I wrote to them sways them with the logic and information that I included. I wish you all the best of luck with your issues.

Missy


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