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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 07-06-2007, 12:42 PM
Ouch! Ouch! is offline
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OK, right now I am really frustrated at the whole situation.

I have Tri-care Standard military insurance. Before my initial appointment with Dr. Zigler at TBI I called to make sure they would cover ADR, get codes, and anything else I might need to know insurance wise. I was told a procedure code and that ADR was covered.

To make a long story shorter, after I scheduled surgery the end of May for July 19, I spoke with the person at TBI who gets the pre-authorization for your surgery. I gave her all the information I had including the Tri-care approved codes. She said she would take care of it, but the code I had was an old one. I said that is the one they said they were using.

Today I got a call that TBI cannot get authorization for my surgery. (They already filed my office visit wrong & it was denied.) I called Tri-care, was told Humana had to do the approvals. Called Humana. They said it was still in the system. That TBI only filed yesterday & it can take 7-10 days for a decision to be made. Since, I gave TBI all the info & scheduled surgery over a month ago, why are they just now trying to get approval??

So, when I thought it was all taken care of, now I find it is all up in the air!

The lady at the Humana approval office said if TBI used the wrong codes, it could be denied & harder to fix. TBI has said the code I gave them is old & not in their billing any more.

I am getting nervous enough over the surgery & everything without all this last minute insurance hassle.

Now that I have ranted, does anyone have any suggestions how to proceed next?

Thanks,

Jane
__________________
DDD L5/S1
No Fusion, please.
Looking for ADR direction
20 years of back problems, no known specific cause
5/9/07 at Consultation Texas Back Institute, Dr. Zigler
7/5/07 Insurance struggles
7/19/07 Prodisk surgery, TBI, Dr Zigler
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  #2  
Old 07-06-2007, 12:47 PM
LBP LBP is offline
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for starters, maybe you could state the codes...what code did you give to TriCare/Humana
andwhich code did TBI submit?

Maybe someone can help given those facts.
__________________
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 07-06-2007, 08:43 PM
Ouch! Ouch! is offline
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The codes I have been told by TriCare were code 0092T, and 22857. The codes TBI used were 22857 and 28899.

I first called TBI in early May and talked with the billing department. I asked them for the codes they used for ADR. TBI gave me 2 codes, 22857 and 28899.

I then called TriCare. I told the lady on the other end of the phone that I was looking into an Artificial Disk Replacement and I wanted to find out if they would approve it. I gave her the 2 codes I had received from TBI. She was nice enough to look it all up and told me that 22857 was the code for Decompression of the Lumbar Spine and it might be covered but would have to go to review. Code 28899 was an unlisted procedure and she did not know if it would be covered. She told me code 0092T, Total disk arthroplasty, was approved. She said that was the approved code they were using for disk replacement.

The code the pre certifying person at TBI gave TriCare was code 22857, after I gave her all the code information from TriCare. Several things complicated the problem. First, she waited until yesterday to call for approval. Second, she insisted on talking with someone instead of letting the authorization travel the normal course through the system. So, the person she talked with told her they wouldn’t cover Prodisk. So, all that has been written down for TriCare to review.

I talked with 2 different people today who told me basically, “TBI has to use the right codes” if I want anything approved. I was also told that the authorization was still awaiting review and had not officially been approved or disapproved. The last lady told me that filing the wrong codes would be prejudicial, see if I can find out the codes that have been used successfully by other doctors at other clinics & see if TBI will fix this before I get a rejection. She was pretty helpful and may have told me more than she should.

I called TBI again and asked if they could use the code that TriCare has repeatedly given me. The response was “it isn’t in our billing system. I will have to see if they will use it.”

Of course, now the clock is ticking. It is Friday so nothing will happen before next week. I have to go out of town until next Thursday. I will be in meetings all Monday. The stress is rising.

Thanks for your help.
__________________
DDD L5/S1
No Fusion, please.
Looking for ADR direction
20 years of back problems, no known specific cause
5/9/07 at Consultation Texas Back Institute, Dr. Zigler
7/5/07 Insurance struggles
7/19/07 Prodisk surgery, TBI, Dr Zigler
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  #4  
Old 07-06-2007, 10:59 PM
LBP LBP is offline
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maybe someone can correct me if I'm wrong, but when ADR was first out of trials...some surgeons were using fusion codes and performing ADR. Then there was a temporary code for ADR which is the 0092T


I just found what you need to know re effective dates of billing codes per CMS/Medicare see: http://www.cms.hhs.gov/Transmittals/...ds/R1164CP.pdf

People before you have had conflicts in coding problems see http://adrsupport.org/eve/forums/a/tpc/f/7701036081/m/1...611067081#3611067081
__________________
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 07-07-2007, 11:22 PM
Ouch! Ouch! is offline
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I can't thank you enough for your help. You have pointed me in some new directions to follow.

From the CMS/Medicare code it sounds like the one to use is 0163T, which neither TriCare/Humana or TBI have mentioned.

As suggested by the Humana person, I called another doctor to ask what codes he had successfully used. They called back & left a message on my voice mail with yet another set of codes.

It is no wonder people can't get there surgery covered with all these confusing codes.

Thanks again,

Jane
__________________
DDD L5/S1
No Fusion, please.
Looking for ADR direction
20 years of back problems, no known specific cause
5/9/07 at Consultation Texas Back Institute, Dr. Zigler
7/5/07 Insurance struggles
7/19/07 Prodisk surgery, TBI, Dr Zigler
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  #6  
Old 07-08-2007, 07:16 AM
Abbe Abbe is offline
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What were the other sets of codes the other Doctor's office gave you?

Abbe
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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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  #7  
Old 07-08-2007, 02:50 PM
Ouch! Ouch! is offline
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The codes the last doctor's office (not TBI) gave me were

22558 Lumbar spinal fusion

22845 Insert spine fixation device

22851 apply spine prosthetic device

Only the last one looks like it might be of help.

Jane
__________________
DDD L5/S1
No Fusion, please.
Looking for ADR direction
20 years of back problems, no known specific cause
5/9/07 at Consultation Texas Back Institute, Dr. Zigler
7/5/07 Insurance struggles
7/19/07 Prodisk surgery, TBI, Dr Zigler
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  #8  
Old 07-12-2007, 09:16 PM
Ouch! Ouch! is offline
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Well, to give an update. Tuesday the insurance company denied preauthorization for Prodisk, meaning they probably won't pay for it. I say probably because I do not have the letter from the insurance yet that tells me in writing the reason for denial.

B_ _ _ _ (name being withheld) that applies for the pre-certification, insists that the insurance is denying authorization because they DO NOT cover ADR. But 5 separate people at the insurance company have all told me it is being denied because Texas Back Institute will not give the insurance company the additional information they have requested. Insurance has said they have mailed me a letter & I have to wait until I receive it to do anything. They can't or won't fax the letter to me.

I spoke with several people at TBI Wed. morning. They want me to send them $19,000 right away as they are supposed to have this 2 weeks before surgery (My surgery is supposed to be next Thursday July 19.) Also the hospital wants me to immediately send them $14,000 just for the disk & they have agreed to bill me for the rest.

I told TBI, that since Dr Zigler has said that he will not know whether he will be able to do the ADR or whether he will do a fusion until he gets inside to the back, that I wanted them to get authorization for the fusion. If I end up with a fusion because Dr. Zigler can't do the ADR I sure don't want to pay out of pocket!

They applied for that authorization at noon Wed.

So, now I am waiting. Insurance has told me I will know Monday whether a fusion is approved. I really want to get the original denial letter before I go ahead with any surgery. If it says they don't cover ADR, fine, that is the end of that. BUT if they say it is denied because they need more information, then I want them to have that information & make an informed decision before I pay out of pocket.

To say I am angry at the situation is an understatement. It is not just the rush to get insurance settled or pay TBI right away. (If I pay out of pocket, we will be borrowing against our house.) Both my husband and I rearranged our schedules and gave up contracts that would have meant income to us for me to have surgery next week. It isn't like we can get those contracts back. They are gone, lost income. Now if there is a delay for the surgery there will be more lost income for my husband when he takes off to go with me for surgery. But we won't know about the insurance until we get the letter. If they need more information, will B_ _ _ _ be willing to get it to the insurance co since she has not been very co-operative so far?

At this point, even though I was impressed with Dr. Zigler, I am not sure TBI is the place to have any surgery, at least for me. I am also having problems getting motivated to pack & get the last minute things done before surgery. Now, I don't even want to go off the meds I am supposed to stop a week before surgery because, what if surgery is delayed.

We are scheduled to fly to Texas Tuesday morning. So, I hope I get the insurance letter soon, though I am not holding my breath because I know it usually takes about a week to get any letters from them once they have mailed them out.

Sorry to be so down, but it really is disheartening to think things are settled, surgery is soon & you will be on the road to recovery and then have it all change.

Jane
__________________
DDD L5/S1
No Fusion, please.
Looking for ADR direction
20 years of back problems, no known specific cause
5/9/07 at Consultation Texas Back Institute, Dr. Zigler
7/5/07 Insurance struggles
7/19/07 Prodisk surgery, TBI, Dr Zigler
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  #9  
Old 07-12-2007, 09:48 PM
ZorroSF ZorroSF is offline
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yes that sounds like quite a hard place. I wouldn't expect insurance to get back to you promptly. I know blue shield is still jerking me around just for seeing a chiropractor and it's supposed to be covered.

If you're set on getting surgery and you have already changed your meds it's a difficult train to stop. I had a similair problem and just decided to bend over for the man rather than deal with the horrible pain. Well I was wrong on both counts and to add to the difficult denial process I am much worse off than had I postponed the surgery. If you really decide on cancelling the op until insurance gets squared around then I suggest using an inversion table. I wish I had used it pre-op for the year running up to the surgery. I probably could've held off the op for 6 more months.
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***********************
1/2006 DDD L5/S1

Prodisc St. Mary's 12/2006 not diagnosed properly pre-op and now have DDD L4/L5, facet calcification L5-S1/L4-L5, mild scoliosis and left knee pain. DDD: C3 through C6
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  #10  
Old 07-13-2007, 06:48 PM
Ouch! Ouch! is offline
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ZorroSF,

Thanks for the in put. It is a hard decision; I have almost decided to wait. I still don't have a response (letter) from the insurance company. Maybe this is the time to take a step back and re-evaluate everything. Something needs to be done, probably surgery. I have no disk left at L5/S1. But may be I should reevaluate the fusion vs adr. In addition, one of the contracts my husband passed on has been reoffered as a possibility if he can be there July 23. (If I have surgery we will be in Texas until July 25.) So, there is also a strong financial incentive to wait.

I tried an inversion table about a year ago; it made me nauseated. My chiropractor is currently doing traction on me about 3 times a week to help releave the pain.

Thanks again for your help.

Jane
__________________
DDD L5/S1
No Fusion, please.
Looking for ADR direction
20 years of back problems, no known specific cause
5/9/07 at Consultation Texas Back Institute, Dr. Zigler
7/5/07 Insurance struggles
7/19/07 Prodisk surgery, TBI, Dr Zigler
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