Nichole,
You're well informed on the local doctors!
It surprises me that insurance companys can cherry pick among approved FDA procedures. How can they fair mindedly propose that an approved FDA procedure is experimental? It seems to be an arbitary opinion motivated by profit incentive. By the same thinking they could extend their argument to deny any medical procedure!
An insurance insider gave me some steps for appeals.
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1) submit to the insurance company a "letter of medical necessity" on your behalf from a US specialist such as neuro or ortho surgeon. Letter should state what surgery is needed and why. submit supporting documents such as radiologists reports, doctor visit notes and the like. Request that they response in writing.
2) If they reject the appeal then you submit all documents, including their rejection, to your state's insurance commission. Attempt to get the state on your side. Once you get the state involved the PPO will supposedly fold. The entire process takes about 6 months.
The PPO may have a patient advocate. The PPO is obligated to tell you who this is. This person may help state your case.
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Back to my situation as an example. I had ADR in Europe in 2003. After the surgery I submitted according to step 1 above and was reimbursed 90% of medical costs. Didn't have to do step 2. I would think the same process is worth a try for preapproval.
It's a shame you have to deal with this. I wish you luck. I hope you're having a low pain day.
Take care,
Jim
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