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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 06-16-2007, 06:54 PM
robby robby is offline
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Join Date: Jun 2007
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I have just been denied a 2 level ADR from Anthem BCBS of Indiana. I am starting the appeal process now. They say that the procedure is, of course, experimental. We pretty much expected it. My doctor's office tells me my doctor is going to do a peer to peer conference with them early next week. We'll see how that goes.
If only some of the people on the medical review board for Anthem and other insurance companies could read this forum. Maybe in my appeal I will list this site for them to review. If they could just see how many people ADR really helps. I am only 38, I don't want to have a fusion now with little or now options for the future.
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39 years old, Female. Loved to run and workout.
August, 2004 Micro surgery for L4-L5
August, 2006 Second Micro surgery for L4-L5
May, 2007 Discogram revealing DDD at L3-L4 and L4-L5.
Dr. Recommended 2 level ADR. Denied three times.
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  #2  
Old 06-16-2007, 07:34 PM
LBP LBP is offline
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Join Date: Aug 2005
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Who's your surgeon? Wow that's pretty nice that's he's willing to get involved in the appeal process that way. Some offices don't do nearly that much. It might help because if you don't ask for peer to peer review, your ins company will get random non-spine surgeons to "review" your appeal. It's really insulting when you find out they had primary care, pediatric phsyicians, or even dermatologist reviewing your spine surgery request!

It wouldn't hurt to submit the federal FEHB policy, a copy of aetna's policy and Medicare's final decision too.

Good luck in the process. Hope you get a better result. Have you talked to Laurie Todd the insurance warrior yet?
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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 06-16-2007, 07:42 PM
robby robby is offline
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Dr. Daniel Laich from Rush Copley Medical Center in Aurora, Illinios. He is very passionate about his work and knows how important this ADR surgery is to give me my life back. He is really going to bat for me.

Funny thing about Aetna is that my husband has it. I never took his insurance because we (my family) had always used mine (for 17 years now.) But if I have to, I can wait until his next open enrollment and get on his insurance. Problem is, that isn't until January and then I don't think I can have the surgery until April. Had I know this a while ago, I would have had him put me on his plan!

I have sent a pm to Laurie. Just waiting to hear back!

Thanks for your support!
__________________
39 years old, Female. Loved to run and workout.
August, 2004 Micro surgery for L4-L5
August, 2006 Second Micro surgery for L4-L5
May, 2007 Discogram revealing DDD at L3-L4 and L4-L5.
Dr. Recommended 2 level ADR. Denied three times.
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  #4  
Old 06-16-2007, 08:23 PM
LBP LBP is offline
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Join Date: Aug 2005
Posts: 446
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Well at least you know that you have a pretty decent back up plan!
__________________
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 06-18-2007, 06:08 PM
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Harrison Harrison is offline
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Join Date: Oct 2004
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Robby, call me some time soon and I can explain some things "behind the scenes" that may help you. Number below.

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"Harrison" - info (at) adrsupport.org
Fell on my ***winter 2003, Canceled fusion April 6 2004
Reborn June 25th, 2004, L5-S1 ADR Charite in Boston
Founder & moderator of ADRSupport - 2004
Founder Arthroplasty Patient Foundation a 501(c)(3) - 2006
Creator & producer, Why Am I Still Sick? - 2012
Donate www.arthropatient.org/about/donate
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  #6  
Old 06-22-2007, 08:24 PM
robby robby is offline
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Join Date: Jun 2007
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Denied again. I just received word today that my first appeal has been denied, once again, because the surgery is considered "experimental and not medically necessary."
Starting appeal number 2. This time with the lawyer involved. We'll see what happens.
__________________
39 years old, Female. Loved to run and workout.
August, 2004 Micro surgery for L4-L5
August, 2006 Second Micro surgery for L4-L5
May, 2007 Discogram revealing DDD at L3-L4 and L4-L5.
Dr. Recommended 2 level ADR. Denied three times.
Reply With Quote
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