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  #1  
Old 08-01-2012, 07:50 PM
Renee Renee is offline
Junior Member
 
Join Date: Jul 2012
Posts: 3
Default Cigna denied coverage

I need a fusion at S1-L5 and ADR at L5-L4. Cigna denied coverage for both procedures. I plan on purchasing The Insurance Warrior by Laurie Todd. Any other suggestions would be Great!! Thanks!
__________________
2002-1st MRI-S1-L5-degeneration started
2011-2nd MRI-S1-L5-No disc left/bone on bone
L5-L4-Bulged Disc
2012-3rd MRI-Suggested surgical procedure of S1-L5 fusion and L5-L4 ADR - Cigna denial on both procedures
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  #2  
Old 08-01-2012, 07:56 PM
Slackwater Slackwater is offline
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Join Date: Aug 2007
Posts: 782
Default

Quote:
Originally Posted by Renee View Post
I need a fusion at S1-L5 and ADR at L5-L4. Cigna denied coverage for both procedures. I plan on purchasing The Insurance Warrior by Laurie Todd. Any other suggestions would be Great!! Thanks!
Get the insurance warrior book. I suggest no "appeals" before you read the book and you have concrete examples of success. There are nuances to insurance that I can not begin to explain.

Cigna's coverage position, for others,
1 level ADR ~OK.
1 level Fusion + 1 level ADR (Hybrid, combined surgery) is specifically excluded in the coverage position the last time I looked.

I asked Cigna about this in an earlier year and they refused to pay for one if I paid for the other to make a hybrid.

ref:
Hybrid construct for two levels disc disease in lumbar spine (full text)
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  #3  
Old 08-01-2012, 08:43 PM
Renee Renee is offline
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Join Date: Jul 2012
Posts: 3
Default

Thanks for the advice. I will read the book before I appeal. The one thing I did think might be of help is that my insurance is actually Boilermakers National Health and Welfare....administered by Cigna. BNHWF state on the Summary of Benefits that they use scientific/medical publications to determine if a procedure is experimental or investigational. I do not know what publications would be considered reputable though or where to find them. I am hoping Laurie's book makes suggestions for this or maybe you would have some knowledge of this. Thanks again!
__________________
2002-1st MRI-S1-L5-degeneration started
2011-2nd MRI-S1-L5-No disc left/bone on bone
L5-L4-Bulged Disc
2012-3rd MRI-Suggested surgical procedure of S1-L5 fusion and L5-L4 ADR - Cigna denial on both procedures
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  #4  
Old 08-04-2012, 03:14 PM
Shay Shay is offline
Member
 
Join Date: Aug 2011
Posts: 59
Default Appealing

Hi Reneen,

I appealed my partner Shay's denial with BCBS successfully even tho she ended up going overseas. I have since become a medical advocate and would be happy to answer questions and get you on the right track.
Have a good day.
Yona
__________________
Diagnosed with bulging disc in L5/S1 in the 90's.
Tried every non-surgical technique over the last 8 years .
2009decided upon Prodisc.
2010 scheduled ADR surgery, denied, scheduled fusion, denied also.
2011 Appealed fusion all the way up. Lost.
Current MRI: moderate foramina stenosis and .collapsed disc in L5/S1. Spurs and fusion of disc also.
L4/L5 small bulge and slight stenosis.
1/18/12 I became Borg. double ADR w/ Mr. Boeree
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  #5  
Old 08-06-2012, 07:17 PM
Renee Renee is offline
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Join Date: Jul 2012
Posts: 3
Default

Thanks for the response and desire to help. Not sure where to start or what to ask. I guess first I am not positive I need the extensive surgery the surgeon is suggesting. If he changes the diagnosis, does that bring negative attention to my situation? My insurance says it will cover ADR at one level when non-invasive procedures have been exhausted. I have gone through therapy (last summer but only with a therapist for 3 weeks-she told me I had a very strong core and really didn't need the therapy) I did continue on my own for about 3 months. I also had one shot in the spine and that was a total waste of money. I tried a NUCCA chiropractor for 8 weeks that was also a waste of money. I am sure what I have done will not satisfy the insurances guidelines of non invasive procedures so I am prepared to go through therapy again if necessary. No more shots though...I have read to much that they cause more damage. Maybe we can start with what were the real red flags that you and your partner found and what suggestions do you have for me? Thanks for taking the time to help. I really appreciate it.
__________________
2002-1st MRI-S1-L5-degeneration started
2011-2nd MRI-S1-L5-No disc left/bone on bone
L5-L4-Bulged Disc
2012-3rd MRI-Suggested surgical procedure of S1-L5 fusion and L5-L4 ADR - Cigna denial on both procedures
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