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Old 06-20-2006, 11:48 AM
go*big*red go*big*red is offline
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Join Date: Jun 2005
Posts: 123
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Hello, again.

I feel like I'm very needy, always needing questions answered and opinions from everyone, and yet cannot add or answer anything for anyone. I'm an ADR recipient wannabe and therefore, do not have the expertise of everyone else here. Nuff of that!

This is the progression of things that have happened in a nut shell with the insurance company after final denial leading up to and including independent medical review.

<LI>Received a letter offering either a second level internal review or independent external review which they send a form for. The internal review request would be done by letter, the external review request done by filling out a form per their final denial letter to me explaining their appeals process.

<LI>With the help of my surgeon's office, we filled out and sent in the request for the external review. They disregarded that request and set up an internal review by use of a panel review over the phone. Stating that that's the way they usually do it.

<LI>Under the stipulations of the "Second Level Internal Review" which I DID NOT REQUEST, they said that I could "be assisted by counsel, advocates and health care professionals". When I requested that my surgeon be present, they denied that request. When I requested that the Charite' representative be present, they denied that as well.

<LI>I had the link posted here showing that UHC had, at the time I printed the chart, approved 3 ADRs. The doctor on the panel review denied that. When, in fact, had I printed a current chart, it would have shown that in fact 6 had been approved and one was in Colorado.

So, that's the sorted chain of pertinent events. Do I have a case? Do you think I've been lied to and hoodwinked and maybe could use this information to get the disc approved? Or is this just the way it goes?

The Charite rep says that because the FDA has approved the disc for only a single level procedure and that the remaining levels need to be intact, that an external review at this point would be hard at best. Probably wouldn't do any good.

The reason why I'm bringing this back up now, even though my surgeon has now suggested the Dynesys system is that the Colorado Division of Insurance faxed me the copy of the denial letter and the letter mentioned above with the form for the external review along with this comment.

"I wanted to make sure you had a copy of the co's 4/25/06 letter to Dr. Pettine w/the forms you may sign (yourself) to bypass other reviews & go directly - "external review"

This was sent to me on the 18th of June. So, I'm not sure if they have a copy of my denial letter yet from the panel review.

OMG - What a friggin mess! So, what do you all think?

Sorry I'm not adding alot to this forum, just alot of stinking questions.
__________________
Juvenile Discogenic Disease
2 level ACDF C5/6, C6/7
Redo on C6/7
PLIF L5/S1 - hdwr removed when C6/7 revision
PLIF L4/5 & Dynesys L3/4 10/10/06. Looking forward to living again.
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