As brevity is key to organization, I deleted another topic to consolidate into this one topic. See below.
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Resources for Insurance Appeals
A constant problem for patients is the challenge of ADR coverage – some plans cover it and many do not. It seems unfair that there are such differences between plans. In reality, some people have been approved by the same carrier that has denied others!
This “rationing” of health care is the end of the road for many; but it need not be so! One can pursue many appeal options before throwing in the towel. For example, Depuy Spine has invested significant resources to the insurance problem and has rolled out useful infotools for ALL patients seeking ADR coverage. It may also be helpful to people seeking other (non-Charite’) devices, so these information services benefit the patient community at large!
Resources for Insurance Appeal
First: See the wide assortment of information resources available on Depuy Spine’s site:
http://www.charitedisc.com/charitede...mbursement.asp There’s also an individual in each state that is chartered to help you – just use the locator!
Second: There are members of this community that are both lawyers and patients. A few of them can answer “quick” questions for you, and a few can represent you as a client. Email me and I’ll put you in touch.
Third: Members here have suffered through the appeal process, many have succeeded. Read through these previous discussions; feel free to PM or email any of these members. All want to help you, some are busier than others but will try to help you! See below.
Getting Insurance in US to pay for Disk Replacement
http://adrsupport.org/eve/forums/a/tpc/f/7701036081/m/9...961037081#9961037081
Anyone that has had 2 levels approved please Help!
http://adrsupport.org/eve/forums/a/t...1/m/1131077081
Medicare approval of coverage for Charite
http://adrsupport.org/eve/forums/a/t...1/m/9901008481
Anyone approved by UHC?
http://adrsupport.org/eve/forums/a/t...1/m/5491077081
Blue Cross of CA Approved!!!!
http://adrsupport.org/eve/forums/a/t...1/m/7801028081
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fiddle
Harrison, I wanted to be sure to thank you for your very informative post about Resources for Insurance Appeals. I recently put together my appeal, and most of what I included came from your suggestions. The Depuy Spine's site was invaluable. I basically followed that outline step-by-step.
I appealed to my secondary insurance company. I didn't even bother with Medicare because when I called they told me they don't cover out of the U.S. unless it is an emergency just over the border.
My appeal included: 1) the original Letter of Medical Necessity; 2) My letter using the Depuy format giving history, experience, need, etc.; 3) The name and phone number of my primary MD for more consultation if desired (as well as the surgeon); 4) A picture and the name and brief literature about the Activ-L; 5) The generic informational approval letters from two other big insurance companies; 6) The Medicare approval of the Pro-Disc for the population under 60 years old; 7) A copy of a study (I think it was a letteski post of several studies to choose from). I chose the one that seemed to be a study about a NUMBER of studies, so it was more inclusive. I also sent along brief info about the AlphaKlinik where I had my surgery, and compared the two costs U.S. vs. Germany. All in all -- 39 pages.
For those who are new to this, I sent it certified mail with a return receipt. And when I filled out the address on the green certified mail slip, I also wrote the number of pages. That way, they can't say, "oh we didn't receive that part of it". I've learned this the hard way.
Wanted to share what I did in case others are looking for ideas. Good luck to all those who are requesting coverage. I will let you know my outcome.
P.S. They were close, but Germany came out $1000 less compared to a U.S. estimate for a one-level. This is calculated based on all medical needs, the surgery, the doctors, the tests, the meds, the klinik, the therapies, etc. This does not include the airfare, hotel, meal, expenses for a family member and all incidentals. Only medically-related.
This message has been edited. Last edited by: fiddle, September 27, 2006 11:18 PM
November 21, 2006, 02:07 PM
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Harrison
Just a reminder that each state has its own procedure to encourage patients to appeal insurance denials. E.g., the state of Mass. spells out their process and provides applications for appeal here:
http://www.ago.state.ma.us/sp.cfm?pageid=1137
888-830-6277
Of course, there is also the Mass. Division of Insurance, Consumer Hotline (617) 521-7794.