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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  
Old 06-27-2007, 10:21 AM
Abbe Abbe is offline
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Join Date: Feb 2007
Posts: 61
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Hello all,

I am not sure this is the correct path to pursue but I figured after 3 denials it might be worth a shot. The State of California Department of Insurance has a claims service bureu where a consumer can request an Independent medical review. I found forms for the patient and forms to be completed by the physician to request a review. One of the criteria listed in the physician's request is that the treatment is considered Experimental/ Investigational and that the doctor believes
1.)The insured has a terminal medical condition, or a life threatening condition, or a serious debilitating condition.
2.) The insured has a condition that qualifies under one or more of the following.
a. Standard therapies have not been effective in improving the insured's condition.
b. Standard therapies would not be medically appropriate for the insured; or
C. There is no more benificial therapy covered by the policy.

I figured I would try this before seeking legal actions which I am sure would be a long and drawn out process since ERISA has now made it a federal process to sue your insurance company.

I am not aware of other states processes but I would think they are similar.

Here is the link to California's Department of insurance Independent Medical Review application.

http://www.insurance.ca.gov/0100-consumers/0020-health-...ed/0020-imr/#whencan

I hope this process is a help to someone and I hope I can get some help this way.

Abbe
__________________
Water ski accident 86'
Chiropractic& PT Pain meds
Discectomy Laminectomy
L5 S1 Partially sacralized
97' epidural injections
L3 L4 ruptured and torn
L4 L5 Almost no disk height left along with osteophytes
Left leg pain and tingling going down back of leg into heel & foot
3 appeals with BCBS no success Lost insurance.
Kaiser Permanente
L3-L4, L4-L5 Prodisc 9/18/09
C5-6 & C6-7 ruptured and looking at hybrid surgery fusion & Prestige ADR
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  #2  
Old 06-27-2007, 11:06 AM
LBP LBP is offline
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Join Date: Aug 2005
Posts: 446
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Don't get your hopes up. I did the "independent" review through the Calif Dept of Ins ...they upheld PacifiCare's denial.
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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
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  #3  
Old 06-27-2007, 11:52 AM
Julaine Julaine is offline
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Join Date: May 2005
Posts: 39
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In August of 05 i went through the review it was a waste of time, they agreed with BC, athough this time since adr is fda approved it could be different.

Julaine
__________________
Back pain 16 years Chiropractic care 1993-1994DX 2003 DDD at L4 5 S 1January 04-Nov 04 Epi Injections October 04- March 05 Morphine, vicodin, Duragesic, June 05:Blue cross denied my two level ADR
august2005 woke up and had no feeling in legs was in
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  #4  
Old 06-27-2007, 12:29 PM
LBP LBP is offline
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Join Date: Aug 2005
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Well, I asked for a review for a 2 level Charite when Charite was approved by FDA and it didn't matter. When I tried to get a second review for a hybrid Charite/fusion they wouldn't look at it...said it was a duplicate request. I ran out of time on my COBRA to argue anything different.

Good luck
__________________
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
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  #5  
Old 06-27-2007, 01:54 PM
LBP LBP is offline
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Join Date: Aug 2005
Posts: 446
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Somewhere (I thought on here) is a heads up on how to best use your state insurance dept. Maybe someone else knows the thread. I was thinking it was a post by the insurance warrior but maybe not.

I think they helped put the pressure on my ins company when they tried to cancel my policy but not so helpful in overruling a coverage dispute.
__________________
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
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  #6  
Old 07-02-2007, 12:43 PM
marilyn michalak marilyn michalak is offline
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Join Date: Jun 2007
Posts: 21
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We need change. In France, the ambulance gives you a ride to the hospital, and they do your laundry there. We just want medical care paid for.
We have to unite. Single claims of injustice are routinely ignored. The insurance industry is wealthy, powerful and corrupt.
We are Americans. It is our job as citizens to get involved, and to effect change.
1) All senators and representatives these days have email addresses. I have mine on file and write a simple message about issues all the time. The more letters they get, the more they pay attention. It takes volume.
2)We deserve and should have health care, even if we got injured at work. It should be simple, and a single payor system might be considered. I personally have three insurance carriers and they all get out of paying. One doctor's office quit taking insurance at all (we do it ourselves) because she was spending so much money paying people to straighten out the insurance mess. And it was questionable whether she would get paid at all or in part.
3) Socialized medicine may not seem appealing to many, but we rank 37 in health care compared to the rest of the world. We Americans could come up with something that would be better than the rest of the world. We have the best medicine here, we just don't get it because of the fraud going on in the insurance industry.
3)We are already using our connections with Oprah and Michael Moore. Whether you like them or not, they are icons, and can help with this issue.
4) ERISA laws hurt the American Worker. They should be done away with, and retroactively if possible. Many disabled people are living on the edge when they purchased insurance through the companies they worked for. Some lose their homes,commit suicide, lose spouses because they have no money coming in.
This web site is a good place to unite. Numbers. Large numbers of people uniting to make a fuss is the only way. Writing representatives, peaceful demonstrations, using connections with celebrities.
Marilyn Michalak
3 level lumbar ADR
Stenum'07
Still suffering from sacroiliac joint dysfunction
Need medical treatments that are not paid for by insurance companies.
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  #7  
Old 07-03-2007, 08:33 PM
ans ans is offline
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Join Date: Mar 2005
Posts: 1,596
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You never know though. Maybe if you kick-butt (tons of references, personal communications, etc.) and someone's in a good mood you'll get lucky.

I have BCBS and they'll flat out deny an ADR naturally claiming it's "experimental" despite FDA approval. Odd.
__________________
Severe, extensive DDD, considered inoperable by Dr. Regan, Lauressen, & some guy at UCLA. Severe foraminal stenosis (guess they can't operate!) and some spinal cord compression that Lauryssen would fix if gets outta hand.
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  #8  
Old 07-07-2007, 10:35 AM
Abbe Abbe is offline
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Join Date: Feb 2007
Posts: 61
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O.K. Thanks for all the replies! I have been working hard on putting this package together. In the middle of sorting everything out paper-wise I contacted "The Insurance Warrior" Laurie Todd the author of the above-mentioned book. She was very helpful and sent me an example of an appeal she had done for another person seeking insurance coverage for ADR Prodisc. She no longer works for individuals but she had sent an example of this Legal & Medical document to me leaving out the names and telling me to plug in my information and edit it to conform to my case. So, that's what I have been doing. Not an easy task since the document she sent me was for someone whom already had an Artificial disc done in 2004 and BCBS covered it and was now seeking coverage for a second disc to be covered by BCBS. Laurie has suggestions of who to send this document to: Medical director of Blue Cross Blue Shield, Director of Managed Care Health Care, State Insurance Commissioner, Dr. who would perform the surgery, Pres. of City Medical Society, Pres. of state Medical Association.

So, I have been busy cutting and pasting and documenting and I currently have 3 different applications for Independent Medical review. I am also scheduled for a test I have never heard of. Instead of an EMG where they stick needles into you and you feel like a voodoo doll I am having a Nerve conduction test done. Has anyone had this test done? How reliable is it? I have heard that EMG tests can give false results.

So, anyway after I get the results and also have another appointment with my Neurologist Dr. I will finish up my epic appeal document and have it sent off. I do not expect that I will get responses quickly so it will be a waiting game.

I also thought of getting in touch with the first doctor who did my Laminectomy, discectomy back in 1992. He is now a lawyer but I am not sure what type of lawyer he is.

Abbe
__________________
Water ski accident 86'
Chiropractic& PT Pain meds
Discectomy Laminectomy
L5 S1 Partially sacralized
97' epidural injections
L3 L4 ruptured and torn
L4 L5 Almost no disk height left along with osteophytes
Left leg pain and tingling going down back of leg into heel & foot
3 appeals with BCBS no success Lost insurance.
Kaiser Permanente
L3-L4, L4-L5 Prodisc 9/18/09
C5-6 & C6-7 ruptured and looking at hybrid surgery fusion & Prestige ADR
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  #9  
Old 07-10-2007, 10:48 PM
spotty14 spotty14 is offline
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Join Date: Dec 2004
Posts: 365
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If I remember right the nerve conduction test they put a device on your skin over certain nerves and zap the area (it hurts!) and measure something about how the nerves function. Some of the areas they did actually forced my leg to move and sort of twitch with each zap. I had this done the same day as the emg. Lots of fun.
__________________
7/05 EMG/Nerve Conduction Tests
8/04 Disqualified from ADR clinical trial due to severe osteoporosis -- getting treatment
3/04 updated MRI
11/2000 IDET L 3/4, L4/5
1/2000 Discogram
numerous epidural injections
physical therapy
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  #10  
Old 07-10-2007, 10:53 PM
spotty14 spotty14 is offline
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Join Date: Dec 2004
Posts: 365
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I've used the appeals process at the California Department of Managed Care to appeal denial of treatment for denials by private insurance HMO's. It wasn't for spine surgery though.
__________________
7/05 EMG/Nerve Conduction Tests
8/04 Disqualified from ADR clinical trial due to severe osteoporosis -- getting treatment
3/04 updated MRI
11/2000 IDET L 3/4, L4/5
1/2000 Discogram
numerous epidural injections
physical therapy
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