Laurie, I like where you're going w/ your strategy tactics. My problem is my husband's employer is privately owned and self-insured, so basically HealthPartners is just acting in an administrative capacity, it appears, under the guidelines of our 2007 health coverage summary plan. Which btw, has still not been finalized or signed by the company head! Every time they deny my appeals, they remind me "it may be helpful to note that all of HealthPartners' coverage policies are available on our web site at
www.healthpartners.com, or by calling Member Services at_______." But, the bitch is, when I go to the website and enter my password, it tells me my coverage policy is not available. Then, I call the member service folks, and they read to me what is covered or not! I don't have a copy in my hands, because it's not signed yet!
For example, I quote from my latest final denial: "Your plan excludes coverage for services that are considered investigative. (this is their only answer every time they deny me..investigative) Although NAME OF EMPLOYER has not yet finalized its 2007 Summary Plan Description (SPD), we anticipate that the benefit provisions, when finalized, will read as follows. Under the heading, Services Not Covered, your SPD reads in part: 2. Procedures, technologies, treatments, facilities, equipment, drugs and devices which are considred investigative, or otherwise not clinically accepted medical services." When they sent my appeal for further review to their medical directors, they said,(in same denial letter as above) "this reviewer confirmed that Artificial Intervertebral Disc Replacement is considered investigative at this time. Additionally, the reviewer asserted that the FDA approved labeling of the ProDisc states that the safety and effectiveness of this device has not been established in patients with the following conditions: pregnancy, morbid obesity, two or more degenerative discs, spondylolisthesis greater than 3 millimeters, or two or more unstable segments. The ProDisc is currently required to undergo a Post Market Study to evaluate its long-term safety and efficacy." I do fall under "two or more degenerative discs" category, but I thought the FDA had approved the ProDisc for 2 levels. I happened to need 3 levels, so went to Germany. But my point is, all of these long winded denial letters, time after time, and yet "the company has not yet finalized its 2007 Summary Plan Description, we anticipate that the benefit provisions, when finalized, will read as follows." How crazy is that? I am being denied on what they anticipate the plan to say, when finalized!! Sorry for the long description. Any advice?