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  #1  
Old 08-25-2014, 04:03 PM
henry4956's Avatar
henry4956 henry4956 is offline
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Posts: 250
Default Appeal using 'External Review' method

I received a denial on my initial request for reimbursement from Blue Cross World Wide. I had 2 level ADR surgery with Dr Zeegers in April.

There are two ways to appeal a health plan decision:
  • Internal appeal: If your claim is denied or your health insurance coverage cancelled, you have the right to an internal appeal. You may ask your insurance company to conduct a full and fair review of its decision. If the case is urgent, your insurance company must speed up this process.
  • External review: You have the right to take your appeal to an independent third party for review. This is called external review. External review means that the insurance company no longer gets the final say over whether to pay a claim.
Has anyone here used the external review process and if so can you elaborate on your story
__________________
Bad fall on A$$, Feb 2001 ice hockey
Lami L4/L5 April 2001, L5/S1 Aug 2001
Severe dislocated coccyx (same fall)
Un-diagnosed til 09. (Cannot sit)
Low back pain mild until 2011 - pull started a generator from knees.
rhizotomy Nov 2011 - zilch
Facet joint inj. 18 mo. (no impact)
Can only stand/walk for approx. 30 min
21 hrs/day in bed
L3-5 Activ-Ls (April 2014) Dr Zeegers - walk every day, swim 3 x week. Pain free, no pain meds. Extremely pleased with my decision
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Old 08-25-2014, 05:25 PM
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henry4956 henry4956 is offline
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Posts: 250
Default David vs Goliath

Just did a search on 'external review'. Not promising. Starting to feel like I am David and Blue Cross is GOLIATH.
__________________
Bad fall on A$$, Feb 2001 ice hockey
Lami L4/L5 April 2001, L5/S1 Aug 2001
Severe dislocated coccyx (same fall)
Un-diagnosed til 09. (Cannot sit)
Low back pain mild until 2011 - pull started a generator from knees.
rhizotomy Nov 2011 - zilch
Facet joint inj. 18 mo. (no impact)
Can only stand/walk for approx. 30 min
21 hrs/day in bed
L3-5 Activ-Ls (April 2014) Dr Zeegers - walk every day, swim 3 x week. Pain free, no pain meds. Extremely pleased with my decision
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  #3  
Old 08-25-2014, 06:25 PM
FranklySir FranklySir is offline
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Posts: 177
Default

Hen,

Second level internal is the first step. Most likely you won't win. You can however resubmit the claim after the second level internal. and or submit to the external appeal. Im going through this right now.

PM me or email better. Don't want to post this here.
__________________
Lumbar issues 18 yrs
herniations lumbar L3-5 multiple Epis etc etc
Annular tears L3-5 cauda equina
Cervical herniation symptoms 2011
C5-7 M6C by Dr Clavel on June 5 2013
L3-5 M6L by Dr. Clavel on 12.18.13
Living life instead of living the condition
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  #4  
Old 08-25-2014, 07:41 PM
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henry4956 henry4956 is offline
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Default

Thanks Frank
__________________
Bad fall on A$$, Feb 2001 ice hockey
Lami L4/L5 April 2001, L5/S1 Aug 2001
Severe dislocated coccyx (same fall)
Un-diagnosed til 09. (Cannot sit)
Low back pain mild until 2011 - pull started a generator from knees.
rhizotomy Nov 2011 - zilch
Facet joint inj. 18 mo. (no impact)
Can only stand/walk for approx. 30 min
21 hrs/day in bed
L3-5 Activ-Ls (April 2014) Dr Zeegers - walk every day, swim 3 x week. Pain free, no pain meds. Extremely pleased with my decision
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  #5  
Old 08-25-2014, 08:07 PM
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jss jss is offline
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Join Date: Nov 2009
Posts: 1,411
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Henry,

The only poster on this site I'm aware of that won a third party appeal for ADR has posted her story in this thread. Her appeal is different than yours in that 1)her surgery was domestic rather than international, and 2)she went through the appeals process before surgery, rather than afterwards as you and I did.

She, gymnast1981, doesn't post here any longer but may respond to PM's. BTW: she almost four years post-surgery and is still doing very well.

Wishing you the best of luck with those disingenuous son-of-a-guns at BCBS.

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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  #6  
Old 08-26-2014, 12:32 AM
Jen93312 Jen93312 is offline
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Join Date: Aug 2011
Posts: 87
Default Encouragement

Some words of encouragement-David won!
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Jen
C3 Bulge
C4 Bulge
C5 ruptured
C6 Bulge
7/2011 epidural that caused a "fragment to present itself"
10/2011 C5-C6 Foraminotomy & removal of fragment
Positive for left-sided Hoffman's reflex
Effacement of anterior spinal artery
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  #7  
Old 08-26-2014, 02:12 AM
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Kelly4ADR Kelly4ADR is offline
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Posts: 259
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A second to Jens comment, won with a small stone I might add, but you know that Henry! Posted in my thread "cervical two level, Aetna" is my lengthy story so I'll spare you here but I just lost to an external appeal, but we talked about that so you know that too!

I am contemplating filing a suit. As that is the final step, not the external appeal like they want you to think. Everyone, under every plan has this option. I'm praying for guidance on it at this point. Not being hasty, but patience is a virtue, even when in pain.

I will send my paperwork to you this week. Let's share share share info. No one has the time or energy to reinvent the wheel (the appeal, in this case) so let's all fight this fight together. I feel every win is a win for everyone. Even though my surgery is denied, there is still perseverance left in me to pave the path for others.
__________________
2004 MRI -cervical bone spur causing pain
2011 MRI -5 bulging discs at C3-7: Recommended C5-6 and C6-7 for a two level fusion, I said no thanks.
2014 MRI -progressive compression C5-7.
MRI 6/5/14- Ruptured L4-5, bulge at L2-3 and L5-S1 Dr recommends discectomy of L4-5 but won't do surgery until cervical is stable
8/2014- 8 months/3 rounds of appeals, Aetna denies 2 level cervical ADR
2 level ADR w/ mobi-c C5-7 Jan 7, 2015
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  #8  
Old 08-26-2014, 12:32 PM
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henry4956 henry4956 is offline
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Join Date: Oct 2013
Posts: 250
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Thanks Jen & Kel, I recently talked to a guy who had surgery with dr Zeegers (2 level lumbar, like me) back '04' with the Charite. He won with his 1st appeal. He sent me his letter - it was very concise and to the point. He says he felt that it was the particular company he worked for who he feels went to bat for him.
__________________
Bad fall on A$$, Feb 2001 ice hockey
Lami L4/L5 April 2001, L5/S1 Aug 2001
Severe dislocated coccyx (same fall)
Un-diagnosed til 09. (Cannot sit)
Low back pain mild until 2011 - pull started a generator from knees.
rhizotomy Nov 2011 - zilch
Facet joint inj. 18 mo. (no impact)
Can only stand/walk for approx. 30 min
21 hrs/day in bed
L3-5 Activ-Ls (April 2014) Dr Zeegers - walk every day, swim 3 x week. Pain free, no pain meds. Extremely pleased with my decision

Last edited by henry4956; 08-26-2014 at 03:44 PM.
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