Quote:
Originally Posted by gclc1457
Hi everyone,
i received bad news today. United hellcare denied me again for adr surgery. My doctor and i have submitted all the correct paperwork, but they continually state that it is an unproven service. I am disgusted with the way they handle the matter, and the treatment you receive from the customer service dept. I was told that its unproven because they don't know the long term effects relating to adr surgery. I hope they don't think they are do this in my best interest. If anyone can give me some advice i could really use it. I really don't want to have a fusion, but i'm aggrevated and in pain.
Thank you
gary
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You state that the denial was based on the assertion that ADR is unproven long term. But how does that assertion relate to the specific provision of the insurance contract (the policy, the document setting forth the benefits terms and exclusions). What I need to know is how the insurance contract somehow allows the insurer to deny coverage because the long term effects of ADRs are unknown.
Does the policy indicate that the lack of long term clincal data renders ADR experimental and/or investigational, and therefore uncovered or excluded?
Does your contract contain a provision that states that even if a service or device is investigational or experimental, it is nevertheless covered if it is deemed medically necessary? If so then you need to make an end run around the experimental/investgational hurdle by demonstrating Medical Necessity as that term is used in the policy.
Look at your policy and post the provisions here.
Regards