[trucklt]

Hi,

I have the NY State Health Insurance Plan for public employees. It's a hybrid plan of Blue Cross/Blue Shield for hospitalization and UHC for medical/surgical. They work together under what is called the "Empire Plan" to limit care as much as possible in order to keep up their quarterly profits. That's probably the kindest thing that I can say about either of them.

I fought them in 2005 for months over a Charite ADR. Apparently they haven't changed their position in 4 years: ADR is unproven technology. The unspoken message I got from them was "get a fusion or stop bothering us."

Under you state's insurance laws, you should be able to appeal to a neutral fact finding panel. If your insurance company hasn't provided the information about an "external appeal" process, contact your state insurance department for information. Before you do your final external appeal, make sure that you have covered all the bases such as failure of at least six months of conservative treatment such as P.T., injections, chiropractic, etc., recent MRI and discograms, and diagnostic nerve root blocks and facet injections to eliminate ANY doubt that your problem is disc related. You will also likely need to provide scientific studies that show the long-term efficacy of ADR. I spent a lot of time in medical libraries and found some good long-term studies about Charite, but they were all from Europe.

I lost my "external appeal" by a vote of 2 to 1. One of the "no" votes just hated ADR and wouldn't approve it for anyone. The other "no" vote made a big deal that I hadn't had facet injections and felt that my workup was incomplete. I later had the facet injections and they weren't the problem. I also got the feeling that the doctors on the review panel could care less about scientific studies done outside the US.

I tried to tough it out in the hope that UHC and BCBS would change their policies on ADR. Unfortunately, I've hit the end of the line and am having a single-level fusion on Feb. 10.

I hope that you have better luck fighting UHC. UHC and BCBS are noted on this forum as being the toughtest to move on ADRs.