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Insurance Hell All insurance-related matters are here: Medicare, worker's compensation, appeals, denials, insights, wins, losses. PRICING is here too. Note: This forum has posts from 2006 forward. Older ones are in the Big File. |
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#1
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Well got a call from the state dept of ins and they agree with the ins co that ADR is experimental! I guess all you recipients and your docs are bucking the powers that be! You're all so lucky that your coverage has joined the 21st century and is not stuck using leeches! Now I'll be paying out of pocket and no recourse except the courts. Hope others have better results than I did.
Missy
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fusion L4-5, Dynesys rods L3-4, fusion c5-6 and C6-7, current problem C-7/T-1 |
#2
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Awwwwww Missy I am So Sorry to hear that...So UNFAIR! I just can not wrap my head around the fact that BCBS can ok this surgery in their other states. And you are a case study in yourself having had the fusion. I really hope you have the energy and your lawyer can just sue the pants off them! Your appeals where superiorly written.....I don't think you could have done any better!(((Hugs)))I will say a prayer for you.I hope you keep up the good fight!
Janey
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*c/6-c/7 herniated disc /pinching nerve causing extreme and radiating pain in back-neck and nubness in left arm and compressing spinal cord from 13mm to 6 mm- cervical steriod injections-physical therapy-lots of meds-* CIGNA insurance revoked my F |
#3
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Missy,
Can you explain a bit more? Did you have your appeal reviewed by an independent third party reviewer? This is another process that you have a right to pursue. In fact, the overturn rate may be up to 50% in some states...
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"Harrison" - info (at) adrsupport.org Fell on my ***winter 2003, Canceled fusion April 6 2004 Reborn June 25th, 2004, L5-S1 ADR Charite in Boston Founder & moderator of ADRSupport - 2004 Founder Arthroplasty Patient Foundation a 501(c)(3) - 2006 Creator & producer, Why Am I Still Sick? - 2012 Donate www.arthropatient.org/about/donate |
#4
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My appeal was also turned down at the state insurance board level--over HealthNet's objections, they did send it to an anonymous reviewer identified only as being an orthopedic spine surgeon associated with a medical school. His comments indicated he either didn't read my appeal or chose to ignore all the points I made, but his opinion was that the procedure is experimental and according to my insurance contract, HealthNet was justified in denying the surgery.
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2001 MVA; C5-C6 disk extruded ongoing physical therapy, exercise and massage ESI's, oral prednisone, trigger point injections foraminal and central stenosis C5/C6 and c6/C7 2007 EMG/nerve conduction shows pattern of chronic radiculopathy January, 2008: Prestige ST Artificial Disk Replacement, C5/6 |
#5
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Rich
It was the independent hearing. It was to the CA state dept of ins, they call it an independent medical review. I have not seen the denials yet, they are in the mail, but apparently the 3 docs, one NS, one ortho and one PM were not impressed by my argument. I refuted the definition of "investigational and experimental" and showed them loads of articles in favor of CADR. I'm guessing that the 3 docs were old school and don't know enough about ADR to do it themselves, so they rule it all "experimental". I'll fill in more details as the paperwork reaches me. I thought I wrote a very well thought out argument and backed it up with peer reviewed articles and expert opinion as they required. Go figures! Maybe CA is not one of those 50% states. They don't have to tell me the percentages of overturned denials. MORE SECRETS!!!!!!!!! Missy
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fusion L4-5, Dynesys rods L3-4, fusion c5-6 and C6-7, current problem C-7/T-1 |
#6
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Janey
Thanks for the hugs! I really needed them! Sahuaro I'm thinking that my docs were equally unimpressed or didn't really read what I wrote. I'll keep you posted. Missy
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fusion L4-5, Dynesys rods L3-4, fusion c5-6 and C6-7, current problem C-7/T-1 |
#7
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Missy,
Sorry you had the same experience as me a few years ago. (also CA) Seems nothing has changed. I was just as frustrated as you. You just have to find a new angle to get ADR coverage. I really really recommend finding a way to get Aetna ins. LBP
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Injured 9/01 Annular tears L4/5 & L5/S1 denied adr by insurance for 2 level charite as well as hybrid fusion at L5/S1 with Charite at L4/5. New ins paid for 2 level lumbar prodisc surgery on 4/7/08 (at age 39) with Dr. Westerlund, at Core Orthop |
#8
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Missy:
I am so sorry to hear about your denial. I hope you continue to fight this as there is no good reason to deny this surgery other than greed as they don't want to pay; period. But please keep paying your insurance premiums and remember; "We love you; the customer." Enough people need to stand up to them and punch them in the nose. It's the only way you get their attention. Hang in there and know that we support you and are there for you. Terry Newton
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1980 ruptured L4-L5 1988 ruptured SI-L5 1990 ruptured C5-C6 1994 ruptured C6-C7 1995 Hemi-Laminectomy C5-C6, C6-C7 Mayo Clinic Bicycle Accident 2004 MRI, EMG, Facet Injections, Epidural Blocks, Lumbar Discogram. Stenum Hospital Surgery November 4, 2006 Prestige Disc C5-C6, C6-C7 Maverick Disc S1-L5, L4-L5 |
#9
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LBP
Sad that things have changed so little over the years isn't it? It's too bad these docs don't keep up with the latest technology after they leave practice and then decide that something is "experimental" when thousands of surgeons are using the devices. In November when I can change ins cos, believe me I'll be checking on the current status of cos okaying ADR! Terry Thanks for your kind words. I'll have to take them to court now as that was my last gasp for appeals. I wrote such a good one, too! Missy
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fusion L4-5, Dynesys rods L3-4, fusion c5-6 and C6-7, current problem C-7/T-1 |
#10
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sahuaro
I wonder if you can file a Freedom of Information Act ("FOIA") request to determine the identity of the anonymous reviewer. It seems to smack of lack of due process (violation of Constitutional law), if I don't even know the name or credentials of my reviewer. I wonder if you would consider checking with your local law schools UofA or ASU and see if they have a legal clinic that would help you with the FOIA request. Of course you're going to get denied by an anonymous reviewer! Does anyone think he/she would be hired again, if they agreed with your ADR appeal? |
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