Quote:
Originally Posted by Robert G
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
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Oddly enough that's the exact same argument I just made to my insurance company. That nothing in my statement of benefits limited procedures based on the lack of long term data. FDA approval was specifically mentioned, but the prestige disc is FDA approved. I'm still waiting on a reply. Below is a paste of what I sent my HR department to forward on to my insurance company.
******, it may also be worth asking Allied to clarify the "General
Limitations" listed in our plan, specifically item 25 on page 18.
Item 25 states:
for experimental or investigational services; or, for treatment
not deemed clinically acceptable by (1) the National Institute
of Health; or (2) the FDA; or (3) the Centers for Medicare
and Medicaid Services (CMS); or (4) the AMA; or a similar
national medical organization of the United States;
This item seems to be the focus of the denials to date. The procedure/device is specifically not experimental nor investigational as it has received FDA approval. It has also not been deemed clinically unacceptable by any national medical organization so I'd like them to detail why the procedure would not be covered if nothing in our plan specifically excludes it. I don't see how this item applies to my situation and I did not find any other items under the general limitations which would apply to my case.
Another question I'd like answered is this; Is precertification
necessary if this is done as an outpatient procedure? Barring complications
there will be no overnight stay at a hospital and in fact the stay should
be less than 12 hours. My understanding is that outpatient procedures do not
require a precert. I was informed of this by an Allied employee I
called when trying to get an answer on one of the appeals. However, the
nature of the procedure and the fact that it will be done at a hospital on an
outpatient basis may affect how the procedure is viewed.
Now I do understand that part of the precertification process is to
review medical necessity but the denials have relied almost completely on the
argument that the procedure is experimental and unsafe. Both of those
statements are countered by the FDA's approval. Their claims of
long-term safety as a reason in my opinion are not justified because there is no
clause in our plan that limits benefits based on the lack of long
term data for an FDA approved procedure(which there is long term data
available as the procedure has been performed in Europe for many years) and because
Allied does cover the procedure based on separate phone
conversations that both myself and my Dr's nurse had with Allied prior to submitting the
precertification request.
As far as medical necessity goes the FDA has determined that
artificial disc replacement is as effective as fusion for the treatment of
degerative disc disease. I have neck pain and radiating pain through both
arms. The arm pain has become quite severe lately along with numbness in my
right hand. With these symptoms I would have been considered an ideal
candidate of a clinical study a few years ago so I fit the "profile" for disc
replacement.