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Originally Posted by VegasGuy13
Thanks for the information. I would hope there is a reference out there somewhere that alludes to Federal employees being approved for a procedure if the FDA has approved it.
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Vegasguy,
I looked up some information I have in my last appeal to BC. It was not BC who paid but the person (I think it was treefrog) sent me a copy of the approval letter from her insurance, Coventry Health Care, which I put in my appeal.
She was a federal employee and this is part of what the letter says:
Our Medical Director has reviewed the information submitted to include, but not limited to, letter of medical necessity, cost estimate of insurance, patient pre-evaluation questionnaire, and Plan language. The predetermination request was elevated to our Medical Director, Floyd Shewmake, MD, for consideration. Dr. S reviewed the prior determination made by our Medical Director Debra Esser, MD, and overturned her decision. He states that the Federal Employees Health Benefits (FEHB) Plan cannot deny the artificial disc as experimental/investigational if it has been approved by the FDA (Food and Drug Administration). Therefore, we are able to approve the artificial disc placement surgery as medically necessary under the Plan's contract of benefits.
this letter was dated April 23, 2009 and was to Dr. Rudolph Bertagnoli in Bogen Germany.
This is why I do not believe that an insurance company can deny any federal employee anything that is FDA approved. So keep trying, chances are you will succeed.
As for material for my appeal, I found it difficult to receive actual approval letters as people worry about the insurance companies' power to take back an approval or money. With a lot of digging, I actually got a lot of information. BTW, the lady who gave me this letter lives in South Carolina and I am sure, she would probably give you a copy if you find her on here.
Happy hunting,
Kimmers
