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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 11-04-2005, 01:29 PM
letteski letteski is offline
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Hi All,

With all the bad new re: Insurance Companies these days I though I would share with you some good news! My insurance "Health Comp" has paid 100% (-deductibles) for my 1 level ADR-ProDisc.

Not sure why they change there mind, they said before surgery that they would only pay for the surgery and not the ProDisc or any complications caused by the ProDisc in the future because it was not FDA approved. This information was presented to me in a letter. As some may remember this was a very stressful time for me and after 3 attorneys showed me the door, I found one and 3 days before surgery he helped me write a letter in response for the fee of...... "ProDisc Study Articles I have from Dr D and a phone call 1 month post-op". What a deal!!!!!!!!

I would like to share with you the "friendly letter" I wrote to my insurance company w/counsel help. It was sent on the day of surgery certified along with a letter of Medical Necessity from Dr D and 4 Study Journal Articles.

Those of you in the fight of your life please feel free to take anything from this letter that my help your fight. There is some legal �mumbo-jumbo� that may have gotten my IC to reconsider. They never responded to the letter, just paid all the bills. I hope this helps others get there life back as well.

Health Comp
Claims Department:

I received the letter you sent on August 12, 2005 regarding coverage for Spinal Surgery with Artificial Disc Replacement.

I have enclosed a letter of Medical Necessity from Dr Delamarter supporting the authorization made by Universal Health Review on July 26, 2005. This explains my decision of medical necessity to have Artificial Disc Replacement surgery with the ProDisc and not the LINK-Charite prosthesis to prevent future medical complication.

I have provided 4 published reports and articles from medical and scientific journals and literature deemed to be authoritative within the professional medical community in the United States supporting the safety and efficacy as compared with standard means of treatments or diagnoses.

Your stated reason, �It has been established the Spinal Surgery with Artificial Disc Replacement (ProDisc) has not been FDA approved and therefore is not a reimbursable expense under the Plan provisions,� appears to be �circular� reasoning. First, someone from the plan must find that the device is experimental, investigational or done primarily for research. Has this been done? If not, insurance should cover the operation and its aftermath. If so please answer the following questions.

Is it your, (the plan) position that the device is experimental? If so please specifically state all your reasons for such a determination. Please state all names and contact information for the person/persons who made that determination, their qualifications and the specific evidence and documentation they relied upon in making that determination. (Give cites to or send to me all documents relied upon). Also include when the information was reviewed.

Is your (the plan) position that installation of the device is investigational? If so please specifically state all of your reasons for such a determination. Please state the name and contact address of the person/persons who made that determination, their qualifications, and the specific evidence and documentation they relied upon in making that determination. (Give cites to or send to me all the documents relied upon). Also include when the information was reviewed.

Is it you, (the plan) position that the device is primarily for research? If so please specifically state all of your reasons for such a determination. Please state names and the contact address of the person/persons who made that determination, their qualifications and the specific evidence and documentation they relied upon in making that determination. (Give cites to or send to me all documents relied upon). Also include when the information was reviewed.

Your letter has caused me a great deal of anguish. I don�t feel that you investigated the device at all and are using the FDA approval process in a manner not contemplated in the insurance document to deny me coverage. You have forced me into a position of having to decide to live in constant pain, and continue to be completely disabled from work, or to accept a universally recognized device that in my Doctors opinion, is not even appropriate to my condition but which you will pay for, or to proceed with no coverage for complications if I use a device which all the scientific literature states is superior and all involved doctors agree is superior for my condition and which has been used over 10,000 times worldwide.

I cannot stand the pain any longer. Putting in an inappropriate device is just stupid and harmful. In my doctor�s opinion, waiting may cause more nerve damage further causing longer delays in my return to work or permanent disability. After consultation with my doctors I have decided to have this operation and have it now because my medical condition demands it. This is the number one disc in use, worldwide! In my opinion as my insurance you, (the plan) should agree to cover this device. This is the best and most necessary medical decision for my immediate future health.

Good luck to all of you in your fight for a pain free life.

God Bless
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Paulette
ProDisc L5-S1 W/Dr Delamarter Aug 23, 2005
L5-S1 DDD Diagnosis 12/04
T-12 Compression Fracture 10/04
C-7 Spines Process Fracture 5/99
http://prodisc2.blogspot.com/
You are my Rock God in you I can do anything
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  #2  
Old 11-04-2005, 01:52 PM
luvmysibe luvmysibe is offline
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Yeah! With all of the negative news and ill feelings regarding insurance companies this is a positive rarity. Hopefully, this will help others in the approval process.

Thanks a bunch!
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  #3  
Old 11-04-2005, 02:29 PM
JeffreyD JeffreyD is offline
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Nice approach! Congratulations on the coverage of bills!
.....are there 10,000 ProDiscs installed in folks worldwide?.....is the Podisc the number one disc in use, worldwide?
I've never heard this before.

Jeff
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15+ years back pain w/ advancing disc degeneration.
2002-2 level lumbar IDET w/ Nucleoplasty (very unsuccessful; huge setback)
Three level lumbar Charite (L3/4, L4/5, L5/S1) with Dr. Zeegers in Munich, Germany: 2/25/05 (successful)
Two level cervical Mobi-C (C5/6, C6/7) with Dr. Zeegers (successful)
Laser Facet Coagulation (left side: L3/4, L4/5, L5/S1 & sacral) with Prof. Dr. Reul (significant reduction in remnant lumbar & sacral pain)
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Old 11-04-2005, 03:08 PM
letteski letteski is offline
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Jeff,

This was a quote from the letter Dr Delamarter wrote for me re: Medical Necessity. He will have to answer to these claims himself. But I am aware that he has consulted with Dr B on their ProDisc patients just recently in Europe. He would know better then I and would not put past a little exaggeration from the cowboy.
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Paulette
ProDisc L5-S1 W/Dr Delamarter Aug 23, 2005
L5-S1 DDD Diagnosis 12/04
T-12 Compression Fracture 10/04
C-7 Spines Process Fracture 5/99
http://prodisc2.blogspot.com/
You are my Rock God in you I can do anything
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  #5  
Old 11-04-2005, 06:35 PM
Kim Kim is offline
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WTG Paulette!!!!
Always nice to hear good news hun
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Herniated disc L5/S1 2000 Discectomy 10/2003 Rhizotomy 8/2004 and 3/2005Discogram 11/04 grade 7 tear L5/S1
L4/L5 Grade 5 tear with herniation and stenosis
Evaluated by Dr Blumenthal at TBI
2/2005 ADR 2 level recommended
2 level lumbar fusion
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  #6  
Old 11-05-2005, 08:15 AM
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Harrison Harrison is offline
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Nice job Paulette, thanks for sharing this. Now you can spend that $ on important things, like skiing, new mountain bikes...
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  #7  
Old 11-06-2005, 02:06 AM
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Bravo Paulette! I'm new here and have read many of your posts and your detailing of your surgery with Dr. D. I had a discectomy by him last year.

You obvioiusly are very tenacious and I greatly admire your persistence. You are very inspirational, and your sharing of your "proven" letter, and surgery is great. I saw your picture in front of the Venice?? boardwalk. I'm so happy to read your story, see your picture and hope that you continue to have great success!

I am trying to get an ADR but Medicare is not paying enough for the hospitals here to book these surgeries. I will write a letter to Medicare and may use some of your wording if that is OK?

Thanks again!
Best wishes!
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  #8  
Old 11-06-2005, 01:30 PM
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Only if All Insurance Companies would pay for AR's then there might be less suffering!!!


sessler
1999 Microdestomy L4-S1-Failed
L3/L4 Buldge Big
L4/L5 Half disc left
L5/S1 ADR Keniflex July 18, 2005
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  #9  
Old 11-06-2005, 06:04 PM
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Good Job Paulette,

I think you were successful in getting your ADR paid for because you were able to put the bill in their court, and they had no legal reason not to pay your legitimate claim. All who are fighting with their insurance co. for authorization should consider this path. The ins. companies can say no all day long and as long as you listen to them and do not proceed with the surgery you and your Dr's think is a medical necessity then they win.

Read your policies and how many days planned stay in the hospital are required before pre-authorization is needed. It is usually 3 or more days. Plan your surgery and get out in 2 days and move to a hotel near buy till your first follow up. All Paulette's letters did not hurt her case, but everyone has a legal contract with their ins. co. and if you follow the terms they must also as well. This is an FDA approved procedure. It is not investigational any more as far as our Government is concerned. It does not matter if your insurance co. still think it is still unproven. If they don't pay quickly then you will have a real claim and damages that are provable. It now becomes a matter of contract law and the law is now on your side.

I hope your recovery continues to go well Paulette. Take care,

Pat
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  #10  
Old 11-06-2005, 10:11 PM
letteski letteski is offline
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Pat,

Very well said thank you. I just don�t know why Insurance Companies have to make the pre-cert. posses such a nightmare. We are in enough pain as it is. What they say and what happens don�t match-up.

I was told by the pre-cert level this was not a PPO hospital or Doctor. When the EOB came the Hospital gave the Insurance Company a �Pro-Net Discount� a $31,000.00 Discount. Something is going on behind the seen that I�m not privie to as the patient and will just say out of this one. Just glad I got this discount. Why can�t Medical patents get this too I�m sure they could afford $6,000 for a 1 level ADR. Hmmmm......

I will pay my deductible and smile all the way to the Post Office.

Freshfig,

Thanks for you kind words I�m glad my story is encouraging you. You can take anything you like form the letter. Welcome to the forum and I hope you find it cozy here I did.
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Paulette
ProDisc L5-S1 W/Dr Delamarter Aug 23, 2005
L5-S1 DDD Diagnosis 12/04
T-12 Compression Fracture 10/04
C-7 Spines Process Fracture 5/99
http://prodisc2.blogspot.com/
You are my Rock God in you I can do anything
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