One Appeal for Coverage

[Judy]

Finally after one long year I won my appeal. I was fortunate to have the States Attorney General and also the State of Connecticut Insurance Commissioner working with me. My second appeal was to take place Thursday at 10:30 am. Both the Attorney General and the Insurance Commissioner were going to be part of the appeal also. They were to call us and at about 10:45 they said they were running late and it would be another 15 minutes, within 10 minutes they called and agreed to pay.
The following is how I won it and why and maybe this can help someone on the board.
Prior to having surgery:
1. I called and explained what I was going to have done and they explained my benefits.
2. Called to confirm
After surgery:
1. Called and asked exactly what information they needed on the invoices to avoid questions or problems in the future.
2. After not hearing for approximately one month called for status/continued doing this monthly.
3. Received written notification of rejection due to experimental.
4. Appealed due to fact the invoices and claim I was processing was for a fusion not the ADR part of the surgery.
5. Received payment for 1 of 4 invoices, the smaller of the four which included back brace, additional cost for private room and husbands meals. Only submitted claim for brace and they paid everything, go figure.
6. For 5 months the claim now was in their review department, conversion department and then again in review department.
7. Received notification in Septemember again denying the claim (3 invoices) for experimental.
8 Very upset again since I only sent them invoices for the fusion portion.
9. Called Cigna and now they claim if done in a separate surgery ( 2 surgeries) they would have covered it.
10. Contacted the State Commissioners Office and they were upset over this and how this was handled and wanted to represent me in the second appeal. She then contact the State's General Attorney and he to wanted to be involved.
11. Attorney General requested the call logs (you know how they also say you are being recorded) well they log, not all calls as I found out but most. It says who called, what for and what they told you.
12. Log clearly states about 75% of my calls and how they told me it would be covered etc. so I believe this is why they finally agreed to pay along with it did not hurt to have other people represented me on this appeal.

What I learned:
They will cover 60% of reasonable and customary out of network benefits. Once I reach my deductible it goes to 100%.
Now what is reasonable and customary is my biggest question and how do I find out?
What is a typic hospital stay for a fusion?
What is the cost of the hardware for a fusion?
What is a customary doctors fee for the surgery?

Anyone know? Anyone had one done recently and what what charge versus what was paid? The Attorney General and Insurance Commission told me to contact them if I have any issues on the coverage I received against the invoices that I gave them.

So this is so long but it was a lot of work and I think they thought I would just go away.

Judy

[Mariaa]

To find out about the fusion material try going to www.stryker.com or the manufacturer of your fusion system.

Reasonable and customary fees are usually explained by the insurance carrier. Talk with your surgeon's secretary also and you can speak directly with the billing dept at the office and hospital.

Typical stay for fusion for healthy person that was authorized by my WC insurance carrier was a 4 day stay after 3 level global fusion (I didn't have it done). I believe the stay can range between 2-4 days. This is also something you can ask the nurses on the unit where you had the surgery done or any hospital as they know how long the average fusion patient typically is allowed by insurance to stay, or you can again talk with the insurance company, or with the surgeon's office.

After my discectomies I got the charges from the WC attorney's office doing the litigation for my case..

[luvmysibe]

Congratulations on winning your appeal. It most certainly should inspire others. It's great to be able to share information on this forum.