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Old 11-04-2005, 02:29 PM
letteski letteski is offline
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Join Date: Mar 2005
Posts: 814
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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
__________________
Paulette
ProDisc L5-S1 W/Dr Delamarter Aug 23, 2005
L5-S1 DDD Diagnosis 12/04
T-12 Compression Fracture 10/04
C-7 Spines Process Fracture 5/99
http://prodisc2.blogspot.com/
You are my Rock God in you I can do anything
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