external reviewer denied my 2 level ADR

[Running11]

Hi Gene,

Thank you for your input and your kind regards.

Regarding your input, I already called seven on your side , they immediately emailed and said they don't work with insurance cases.

I was told on Friday by BC/BS that they wouldn't answer anymore questions regarding my case, after issuing complete denial they rescinded again and said they would give me a partial. Meaning they would pay for ADR/fusion at C 5-6 but not C 4-5 My doctor thinks the doctor who reviewed my case didn't even read any of my medical tests or reports because it's as clear as day to ANYONE on my MRI that C4-5 is in worse shape than the C 5-6. This is so frustrating. I am so mad and angry .:

However, my spinal surgeon said that with the partial ; I got a lot further than he's been able to get. He is around 62. So, he recommended that I get the partial- procedure because I need it.

His office is waiting for my precertification in WRITING before we set -up my surgery date.

Gene, I am so exhausted ( and so are my family) by this fight that I NEED a break so getting one level done will offer me that. I swear I would drop my kids off from school and work mostly ALL day 7 days a week pushing to get this approved. I sent them 63 pages of studies , hospitals that perform ADR, cases and my medical records on why they should approve ADR. It took a lot more time and energy than I thought it would. I saw 13 Doctors, yes doctors and everything the doctors asked me to do I did. In the end BC/BS just had me chasing my tail. For example, after they denied my procedure at the external level they told me to go visit each doctor and have them write a rebuttal. Idiots. Then, two days later they said they wouldn't accept any more tests or opinions from my treating physicians .(this is after the denial at the external level.) Are you kidding me; this weas your idea in the first place.

They even denied my second level of appeal. They were very dirty and they bullied me by calling me at 8 am or 6 am telling me they they were just going to keep denying my procedure so why bother . They then said my husband was the cause of the second appeal never getting put through. The representative said my husband said don't put it in unless you answer all our written submitted questions. That was a twisted lie on their part! One of my questions was why was a foot doctor was denying a spinal procedure? I think I could write a book on their dirty behavior. A bunch of bullies. They are Bull Crap Bull **** in my mind. I may still have to file a law suit against them.

BC/BS made somewhere around the ballpark of 455 BILLION in profit last year… yes ,billion dollars. They are a bunch of criminals . I am sorry to offend anyone who works for an insurer such as BC/BS but how can you sleep at night denying sick and dying people of life-saving procedures? Watch the movie Sicko and you'll see what I mean. Senoir citizens losing their houses because their insurance is denying a life-saving procedure. I could never take those calls all day or send out denial letters all day.

I need a much needed break from insurance hell. A break… I 'm not giving up or going away. Thank you for letting me vent!

Thank you Gene for you advice.

[NJ Gene]

Tammi,

I saw Sicko when it was out and I know what you mean. Good luck with the surgery that you are going to get. Hopefully that will help a little bit. Perhaps you need a break to get this surgery done and recover. Then maybe at the proper time, catch BCBS off guard and sue them!!

Warm regards,
Gene

[Running11]

Thanks Gene.. that sounds like a plan!