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Old 02-13-2017, 06:40 PM
Nestletea Nestletea is offline
Join Date: Nov 2016
Posts: 33
Default Florida Blue - Denied ActivL Lumbar TDR

I had lumbar TDR scheduled February 15, 2017 with Dr. Rolando Garcia in Miami, Florida. Their office submitted for approval and the procedure was denied due to being "experimental/investigational." I then submitted an expedited internal review. Florida Blue had 72 hours to make a decision and I was again denied. This was after I sent in approximately 1000 pages of medical records and my surgeon completed a peer to peer review twice. The first peer to peer was done unfairly (family physician to surgeon). My surgeon then asked for a second peer to peer review with another board certified spine surgeon. Florida Blue again denied the procedure. Today I sent in an Expedited external review. This contained all of my medical records, 25 research studies that favor lumbar TDR vs fusion and all of the insurance companies that offer positive coverage (this includes some BCBS plans). There is another 72 hours to make a decision. If anyone has any other suggestions, it would be greatly appreciated!

1/8/2016 - Microdiscectomy L5/S1
3/17/2016 - Cervical Disc Replacement C5/C6 (Mobi-C)
10/19/2016 - DeKompressor Wand L5/S1
1/16/2017 - Cervical Radiofrequency Lesioning
3/15/2017 - Dr. Pablo Clavel: Cervical Disc Revision C5/C6 (M6-C) and Lumbar Disc Replacement (M6-L)
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