I won my appeal with BCBS!!!

[Andi Lea]

I needed artificial disc replacement at my L5-S1, but my BCBS insurance has a policy against it calling it “investigational”. I didn’t have the funds to pay for the surgery out-of-pocket and I was hesitant to appeal as I read every thread on “Insurance Hell”. Nonetheless, I did appeal. Three weeks after my submission, I received a letter of denial based upon my DDD and retrolisthesis on a different level. However, I was granted several days to submit any further material before my case was closed. I wrote a rebuttal letter as well as my surgeon. The day after they were submitted, BCBS approved my lumbar ADR. I had the surgery last week and am now at home recovering. My surgeon was Dr. Richard Guyer at Texas Back Institute. My husband and I have only praises for Dr. Guyer and TBI.

I appreciate everyone on this site that has contributed information. It helped me in writing my appeal……an appeal that won on the first level. I know how difficult and time consuming it can be to compose an appeal. I have made a file with my appeal letter and my rebuttal letter on it, though all personal information has been edited out. If you face writing one and are interested in viewing mine, send me a private message to receive a copy. My hope is that it will somehow be of help.

[jss]

Andi,

Congratulations on winning the appeal AND on a successful surgery! From what we've see on this board, reversals from BCBS are very unusual. I'm certain that your appeal will be very valuable to others in that position.

Here's hoping for a successful and uneventful recovery.

Good luck, Jeff

[Harrison]

Congrats, Andi! I heard that Texas Back has comparatively higher numbers of successful appeals, so that's great!

Keep us posted on your recovery...

[Andi Lea]

One of the latest events to use in appealing for ADR happened in July, 2013. That was the date CIGNA lost the case filed by Danica Dubaich for multilevel ADR. The judge ruled that "CIGNA failed to prove that two-level ADR is an experimental procedure from the Plan's Coverage" and thus, Dubaich was entitled to coverage from CIGNA for multi-level ADR. That event not only dubunked the "experimental/investigational" reason many insurance companies use, but also set a new standard: one can now have two levels of DDD and still be entitled to ADR as dictated in the court of law. It doesn't mean insurance companies will change their denial policies, but it has set a new precedent that people in need of ADR can utilize.

[2Confused]

Congratulations!!! This is awesome news!!!

[Grover771]

Andi, that's AWESOME news! I just sent you a PM. Let s know how you're doing.

[Andi Lea]

Thank you for your congrats and support. I am doing fine in my post-surgery. I was essentially bone-on-bone and the surgeon said he had to do quite a bit of maneuvering to make space to accommodate the disc. Because of the stretch in my facets, muscles, ligaments & tendons he said I would experience post-surgery pain for about 3 months. Well, he's correct. I am experiencing pain which causes me to move around slowly and cautiously. I have plenty of pain meds, but am trying to cope without them as I don't like the side effects. I start physical therapy tomorrow and I look forward to that. I'll update, again, in several weeks.

[pittpete]

congrats
Keep us updated on your recovery please...

[bohnrods]

Glad you are doing well. I was pre-approved BCBS for ADR @ stenum in 2007 in less then 24 hours. They paid 100%. Then I became a NC resident and got denied for same surgery one level down by BCBS NC one month ago. Now I am waiting for pro-spine to submit paper work to BCBS world office for pre-approval overseas. I have no idea what will happen next but should know soon. I would be interested in exchanging thoughts and other information if you are interested.

Brian Bohn

Originally Posted by Andi Lea

Thank you for your congrats and support. I am doing fine in my post-surgery. I was essentially bone-on-bone and the surgeon said he had to do quite a bit of maneuvering to make space to accommodate the disc. Because of the stretch in my facets, muscles, ligaments & tendons he said I would experience post-surgery pain for about 3 months. Well, he's correct. I am experiencing pain which causes me to move around slowly and cautiously. I have plenty of pain meds, but am trying to cope without them as I don't like the side effects. I start physical therapy tomorrow and I look forward to that. I'll update, again, in several weeks.

[Kelly4ADR]

Andi,

Congratulations and I wish you a fast recovery and continued pain relief as time goes on.

I would really appreciate a copy of your appeal paperwork as I am preparing for a denial from Aetna for my cervical two level. Did you use the Cigna case as part of your case for appealing their decision? I will pm you as well to request a copy. Thank you so much for sharing this information.

Kelly