I had my appeals panel review Tuesday. The hearing went as well as it could have on my end. They told me several times that they were very impressed with my appeal and presentation. They even commented that I should come and work for them. I actually spoke well (many times I don't) and was very sharp and accurate with my information. I credit this forum and the Insurance Warrior for the majority of my appeal packet and background information. Your information is invaluable!
Anyway, after my presentation, they told me they could NOT change their policy on this type of surgery, they did not have the authority to do so. I don't understand how it can be called an appeal if they already knew they could not change the decision. I told them it was pretty much a waste of my time to come there (2.5 hours each way including the lawyer) if they could not reconsider their position on this type of surgery.
After again complimenting me on everything, they did, however, say they would expedite my appeal to an outside review doctor, something that seemed like they did not have to do. This outside reviewer has no connection with my insurance company and will be a neurosurgeon just like my doctor of choice. If this outside reviewer says I need this, then they WILL cover it. They say about 14 - 20 days before I will know.....more waiting.
My lawyer actually thought it went pretty well, as there was quite a bit of dialog between us and them, much more than we thought there would be. We thought we would get our 15 minutes and then they would kick us out. But we actually were in there with them for about 30 minutes and had some good conversions. If nothing else, I feel that panel is sooo much more educated and informed about ADR and something good should come out of this. The insurance company is reviewing its policy regarding ADR next month, and I would like to think that I helped inform them.
So I don't have the official denial of the appeal yet, but it should come in the mail any time now. But I still have hope of the outside review doctor. Anyone have good outcomes with that?
Robby
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39 years old, Female. Loved to run and workout.
August, 2004 Micro surgery for L4-L5
August, 2006 Second Micro surgery for L4-L5
May, 2007 Discogram revealing DDD at L3-L4 and L4-L5.
Dr. Recommended 2 level ADR. Denied three times.
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