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  #1  
Old 04-02-2013, 12:56 PM
Running11 Running11 is offline
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Default External review denied; lawyer?

Hello Friends,

Has anyone had any luck from the assistance of retaining a lawyer in getting their ADR/fusion paid for ? I have already completed BC/BS appeal process and have been denied at the external level (third party reviewer) . I need to start working on the next steps. I am not giving up and my husband is not going to support a trip oversees. (although, I still working on him, too!)

Thank you.
Tammi:
__________________
disc bulges C 4-5 and C 5-6
EMG evidence nerve root blockage at C6, C8 and L5
Cogential moderate-severe cervical/lumbar stenosis
Cervical compression with clinical myelopathy with Hoffman's
Tests; MRI's, EMG/NC studies, discogram, CT scan
Pain management; tens unit, ice and heat, physical therapy, chiropratic care, and spinal epidural treatments.
Blue Cross / Blue Shield of Ohio external third party approved Pro-C ADR at C 5-6 on 4/3/13
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  #2  
Old 04-02-2013, 02:47 PM
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jss jss is offline
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Posts: 1,411
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Tammi,

Back when I was pursuing reimbursement from BCBS, this was one of the avenues that I researched. Almost every lawsuit I found against BCBS had to do with anit-trust. I found a few large class action lawsuits filed by large entities, like cities, states or doctors. I didn't find individuals filing lawsuits. Plus, BCBS had placed in the service contract of my policy a great many aces-in-the-hole that gave them unilateral power to deny anything that fell into a grey area. Because it didn't look promising, I didn't pursue the issue even as far as consulting an attorney.

Here is an a lawsuit against BCBS that smells a lot like yours; but it is a huge class action suit (unlike yours) and I don't think it will be of much help (or encouragement).

Another poster on this board finally convinced her husband of the merits of an overseas lumbar ADR with Dr Boeree; and today she is surfing, dancing, etc... She explained to him that it would be cheaper to fix her than to trade her for an undamaged model. She was only joking with him (I think).

Good luck, Jeff
__________________
C4/5 - ACDF in 2000
C5/6 - ACDF in 2002
C3/4 & C6/7 - M6 ADR, Nov 2009, Barcelona
Conceded defeat to a manifestly disingenuous BCBS-TX in my quest for reimbursement, Jan 2011
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  #3  
Old 04-02-2013, 11:23 PM
Running11 Running11 is offline
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Jeff,

Thank you for the valuable feedback. I really hate BC/BS?

They will approve 1 level ADR or fusion at C5-6 . Should I do ADR even though C3-4 needs to be done? The internal reviewer won't approve any surgical intervention. Is it a waste of ime to do one or should I wait until C3-4 deteriorates further or until BC/BS approves of it.
__________________
disc bulges C 4-5 and C 5-6
EMG evidence nerve root blockage at C6, C8 and L5
Cogential moderate-severe cervical/lumbar stenosis
Cervical compression with clinical myelopathy with Hoffman's
Tests; MRI's, EMG/NC studies, discogram, CT scan
Pain management; tens unit, ice and heat, physical therapy, chiropratic care, and spinal epidural treatments.
Blue Cross / Blue Shield of Ohio external third party approved Pro-C ADR at C 5-6 on 4/3/13
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  #4  
Old 04-03-2013, 12:09 AM
Running11 Running11 is offline
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Join Date: Jan 2013
Posts: 187
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Jeff,

Could you please tell me what your recovery time was like after a one level cervical ADR? I am considering getting the one level approved at C 5-6. What limits were you placed under? Driving? Pain level? Thank you very much.

Tammi
__________________
disc bulges C 4-5 and C 5-6
EMG evidence nerve root blockage at C6, C8 and L5
Cogential moderate-severe cervical/lumbar stenosis
Cervical compression with clinical myelopathy with Hoffman's
Tests; MRI's, EMG/NC studies, discogram, CT scan
Pain management; tens unit, ice and heat, physical therapy, chiropratic care, and spinal epidural treatments.
Blue Cross / Blue Shield of Ohio external third party approved Pro-C ADR at C 5-6 on 4/3/13
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  #5  
Old 04-03-2013, 01:13 AM
newleaseonlife newleaseonlife is offline
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Posts: 101
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Tammi,

I had a one level ADR done and am currently seeking reimbursement from BCBS. I chose to only do one level at the time of my surgery. I had a successful surgery. My pain went from being in the 7-8 range to a 2-3 without medication within a couple of months. I had to wait to swim until the incision healed completely, and I had 4 weeks of no driving time. Feel free to PM me your questions about my surgery and recovery experience.
__________________
02/2010- Car accident resulting in C4/C5 & L5/S1 bulging and extruding discs.

06/2012- Successful ADR surgery for C4/C5 disc in Cyprus using PCM by NuVasive. Performed by Dr. Mark Peterson through the help of AIMIS.

09/2012- Successful Disctectomy of L5/S1also performed by Dr. Mark Peterson.
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  #6  
Old 04-08-2013, 10:48 PM
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jss jss is offline
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Posts: 1,411
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Tammi,

My experience with the double ADR was pretty much the same as newlease's single level. Clavel's only limits were, if it hurts, don't do it. I think he's a little stricter now. I was 100% ambulatory and able to attend to all of my daily needs within 24hrs of surgery. It was a further 5 weeks or so when I was able to do literally anything I wanted. Pain-wise, I used ibuprofen for two days after checking out of the hospital. Pain level was 1-2.

A not on planning to do two surgeries when it could all get done with one... There are inherent risks every time you go under anesthesia. The risks aren't high, but people do die from that every day. Unfortunately your insurance dilemma may necessitate two surgeries, two recoveries, meeting your deductible twice, etc...

Good luck, Jeff
__________________
C4/5 - ACDF in 2000
C5/6 - ACDF in 2002
C3/4 & C6/7 - M6 ADR, Nov 2009, Barcelona
Conceded defeat to a manifestly disingenuous BCBS-TX in my quest for reimbursement, Jan 2011
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  #7  
Old 04-10-2013, 01:02 AM
Running11 Running11 is offline
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Join Date: Jan 2013
Posts: 187
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Thanks Jeff and New lease on life!

Jeff if possible could you please tell me why you gave up your quest for reimbursement from your insurance ? In my opinion you deserve reimbursement. No one should have to live on pain meds and be denied. Who knows maybe I should be the next insurance warrior? Ha!
__________________
disc bulges C 4-5 and C 5-6
EMG evidence nerve root blockage at C6, C8 and L5
Cogential moderate-severe cervical/lumbar stenosis
Cervical compression with clinical myelopathy with Hoffman's
Tests; MRI's, EMG/NC studies, discogram, CT scan
Pain management; tens unit, ice and heat, physical therapy, chiropratic care, and spinal epidural treatments.
Blue Cross / Blue Shield of Ohio external third party approved Pro-C ADR at C 5-6 on 4/3/13
Reply With Quote
  #8  
Old 04-11-2013, 12:28 AM
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jss jss is offline
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Join Date: Nov 2009
Posts: 1,411
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I sent in three appeals, each one burying the reason for denial prompted by the previous appeal. On the last denial they finally cited a reason a reason for denial (albeit, a stupid one) that I couldn't argue. My policy stated plainly that a procedure done in a foreign country would not be covered if I traveled there specifically for that procedure.

Here's the sequence of appeals denials:
  • My initial claim
  • Denied, claiming not medically necessary
  • First appeal showed medical necessity
  • Denied, claiming procedure was experimental
  • Second appeal showing 800 years of clinical findings an numerous citations of them having covered that procedure before
  • Denied, claiming it was against company policy to cover my procedure
  • Email from the HR director of my employer asking for an explanation
  • Denial citing three reasons for denial (two of which were patently false). The third was that I traveled to Spain specifically for this treatment, which they weren't required to cover.
You can see that pursuing reimbursement by legal means was hopeless.

Wishing you better luck.
__________________
C4/5 - ACDF in 2000
C5/6 - ACDF in 2002
C3/4 & C6/7 - M6 ADR, Nov 2009, Barcelona
Conceded defeat to a manifestly disingenuous BCBS-TX in my quest for reimbursement, Jan 2011
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  #9  
Old 04-13-2013, 11:00 AM
Running11 Running11 is offline
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Join Date: Jan 2013
Posts: 187
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Hi,

I have been approved for a one level ADR C 5-6. Strange , my doctor said C4-5 is worse. He says the external (third party) couldn't have looked at any medical result findings. They are just a bunch of stupid bean counters. Even stranger, they said I specifically said I couldn't have ANY SURGICAL intervention at levels C 4-5. The reviewer said not even a fusion. My surgeon was not happy because he said I really, really need it. The reviewers must be rewarded heavily if they deny.

I know I can't lose hope and will be taking more MRI's at the sixth month mark and challenging them once again.

I am glad you were able to get yourself fixed? How are you doing with pain and nerve pain? Are they both resolved?

Tammi
__________________
disc bulges C 4-5 and C 5-6
EMG evidence nerve root blockage at C6, C8 and L5
Cogential moderate-severe cervical/lumbar stenosis
Cervical compression with clinical myelopathy with Hoffman's
Tests; MRI's, EMG/NC studies, discogram, CT scan
Pain management; tens unit, ice and heat, physical therapy, chiropratic care, and spinal epidural treatments.
Blue Cross / Blue Shield of Ohio external third party approved Pro-C ADR at C 5-6 on 4/3/13
Reply With Quote
  #10  
Old 04-13-2013, 12:29 PM
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jss jss is offline
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Join Date: Nov 2009
Posts: 1,411
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I am subject to some minor arm pain after a considerable physical exertion, like digging out a tree stump or running a marathon. It passes within a day and I've never so much as taken an aspirin for it.

However, if you come out of surgery with a perfectly placed ADR at a level that is not your main pain generator, you aren't going to feel much better than before surgery.

That is quite a dilemma that your insurance company is creating.

Good luck, Jeff
__________________
C4/5 - ACDF in 2000
C5/6 - ACDF in 2002
C3/4 & C6/7 - M6 ADR, Nov 2009, Barcelona
Conceded defeat to a manifestly disingenuous BCBS-TX in my quest for reimbursement, Jan 2011
Reply With Quote
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