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The Big File All issues not easily categorized in the above forums are here. Comments on general health, diet, "getting comfortable," and more are here.


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  #1  
Old 02-18-2007, 08:20 PM
Nairek Nairek is offline
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Well, I got my denial to my 2nd level appeal on Friday. I was only able to convince 1 of the 3 "doctors" to side with me. I guess I should be happy that I got at least 1 to agree.

After reading the report several times, I just got more & more ticked off at these quacks. One dumb SOB had the nerve to say that my pain was in my head. That's a pretty dangerous observation from someone who's never even seen the patient.

The other dumba$$ just listed things that weren't true & had these "doctors" read the literature that I sent and my OS's reports, they would realize just how dumb their responses were.

I'm just so emotionally drained at this point. I was lead to believe by the folks at my insurance company that I would likely see their decision overturned by the 2nd level appeal. I don't even know where to go from here now other than to crawl into a dark hole & stay there. Maybe then my brain will tell my back & neck to stop hurting. Thank you for listening to my ramblings. I'm off to attempt the homework I've put off for the past week.
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----Karin----
Disc Bulge C4/C5, Disc Degeneration T11/T12, Bi-Lateral tears L5/S1, Diagnosed w/ Lumbar Disc Derangement w/ Radiculopaphy. Treatment: IDET, Percutaneous Discectomy, SI Joint Injection, Facet Block. All failed. Empire BC/BS Denied Coverage for ADR-lost all of my appeals. MVP also denied coverage.

ALIF/PLIF Fusion 1/20/09
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  #2  
Old 02-18-2007, 09:00 PM
LBP LBP is offline
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I am so sorry... sorry for you and sorry that I personally know how you feel!

these drs are paid to tell the insurance company what they want to hear. You could see 10 more treaters and never come close to the opinions you've read in that report.
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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 02-19-2007, 08:41 AM
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Harrison Harrison is offline
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Karin, I am sorry about this setback. I'll noodle this a bit more, let's catch up soon.

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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
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  #4  
Old 03-01-2007, 07:52 PM
Nairek Nairek is offline
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Thank you both for listening to my rant. I needed to step back for a bit & try to regroup hence why it has taken so long to get back to you.

It is absolutely unreal that a health care insurer can sit there & deny medical treatment to someone who so desperately needs it. Everyone I speak to about this is shocked that this sort of thing happens.

From the looks of things, it seems that I am fresh out of appeals. I'm not sure what my next step will be. I'm still really bummed out about the decision & haven't really thought about it. In the meantime, I'll just hold on to the hope that my numbers come up in the Mega Millions drawing on Friday night.
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----Karin----
Disc Bulge C4/C5, Disc Degeneration T11/T12, Bi-Lateral tears L5/S1, Diagnosed w/ Lumbar Disc Derangement w/ Radiculopaphy. Treatment: IDET, Percutaneous Discectomy, SI Joint Injection, Facet Block. All failed. Empire BC/BS Denied Coverage for ADR-lost all of my appeals. MVP also denied coverage.

ALIF/PLIF Fusion 1/20/09
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  #5  
Old 03-05-2007, 09:38 PM
Texas-T Texas-T is offline
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I'm so sorry. I wish I knew the answer, it's just not fair or right.

Thinking of you
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Tear L5/S1 (Pain generator)
IDET 2003 L5/S1 Failed
Shots, MRI's, PT, Drugs & All that Jazz
ADR L5/S1 May 17th 2006 w/Dr. Bitan
http://adrrecovery.blogspot.com/
Doing GREAT and feeling very lucky!
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  #6  
Old 03-07-2007, 07:51 AM
JFerg JFerg is offline
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Nairek...........I'm not sure how it works in N.Y. or with your insurance co. I have been denied 2x's by United Health Care in writing to me personally and once with the surgeon and I jointly composing a letter. That whoe process took up to a year to get through. My insurance co. says my next alternative is either through my employer requesting to the co. or through the state insurance commission in Tallahassee. I've chosen the state route as I didn't want the employer here going into my personal life any further than they must. I've also sought counsel from an attorney whose specialty is insurance claims. Of course, all this requires time, patience and money. In the meantime, I'm doing all I can not to allow the pain to control my life. I'm taking advantage of the procedures my insurance co. does cover (that's also a step to seeing that all my bases are covered), but I've gotten fairly good results recently from some of the procedures. Like the Manipulation Under Anesthesia really opened up the lower back and legs - a big relief. More recently, a shot into the piriformis muscle to attempt to relieve my constant companion - sciatica. Some relief from that though I'm not a big believer in the injections. So while you're doing some consideration on your next move and since our problems are quite the same, there are some open doors to keep knocking that lead to other open doors......resilience is not born but created................all the best to you.....we're listening and with you.
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DDD diagnosis - denied disc replacement by United Health Care 3x's - Recently, Manipulation Under Anesthesia procedure - much needed relief from constant pain.
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  #7  
Old 03-07-2007, 11:47 AM
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Terry Terry is offline
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Nairek:

I can't speak for your personal financial situation but this is what I had to do. I had a lawsuit going on over the accident that caused a collapse in my spine of previous damaged discs. Blue Cross denied the local surgeon's payment for putting in 2 Charite discs in my lower spine. He wanted 55,000 for 2 discs (Charite). I then went to Germany and had 4 level ADR surgery at a cost of 60,805.00 plus travel, hotel, food for two. Blue Cross denied that surgery claiming it was investigational. I had the surgery and got money back from my lawsuit. I shelled out 73,000 from the time of the accident out of my pocket for co-pays with surgery on my damaged shoulder, medications, MRI's, myleogram, discogram, epidurals, trigger point injections, etc., etc. I got 71,330 after my attorney was paid. I then got 3700 from AFLAC leaving me with a little ahead money. Considering I got nothing for two years of pain and suffering after the accident I did not get rich. I received word two weeks ago that Blue Cross paid my surgery in full. The hospital in Germany has since wired my money back to me.
You may look overseas to get cheaper surgery and get it refunded vs. very expensive surgery in the States not being covered.

Definitely a risk but it paid off in the end. I've seen one level bills in the States running as high as what I got having four levels done.

Good-luck and continue to fight the good fight.

Terry Newton
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1980 ruptured L4-L5
1988 ruptured SI-L5
1990 ruptured C5-C6
1994 ruptured C6-C7
1995 Hemi-Laminectomy C5-C6, C6-C7 Mayo Clinic
Bicycle Accident 2004
MRI, EMG, Facet Injections, Epidural Blocks, Lumbar Discogram.
Stenum Hospital Surgery November 4, 2006
Prestige Disc C5-C6, C6-C7
Maverick Disc S1-L5, L4-L5
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  #8  
Old 03-09-2007, 02:02 AM
ZorroSF ZorroSF is offline
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Terry's right. My hospital in San Francisco is trying to charge me and my insurance company $140,000 for one level prodisc. you can forsee the mind-numbing thievery taking place here in the US, so if you can afford it just go to germany. After your surgery you'll have a lot more energy to chase insurance companies.
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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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  #9  
Old 05-14-2007, 09:12 PM
Nairek Nairek is offline
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Hi everyone, once again, please forgive me for taking so long to get back to you. I've just had a lot of stuff going on in my life & had to take a break from posting for a while. I have lost all of my appeals with my insurance company. I have also chosen to appeal to the NYS Dept. of Insurance. They sent my appeal to an "outside reviewing authority" who upheld my insurance company's decision. While I have appealed this decision, & hope to get off my duff & appeal the denial again, in my heart I know I have lost my fight to have Empire pay for this procedure.

As for going to Germany to have ADR surgery, I have thought of it. I do have family there. They are a few hours away from Straubing. I would have to ask my mother to go with me so she could translate. What keeps me from going thru with the decision to go is money. Until I can get that figured out, I'm kinda left out in the cold.

Years ago, when my mom came to America, she needed surgery on her hip & leg. She found a wonderful doctor at NYU who was kind enough to take her case just about pro bono. Wouldn't it be great if there were still doctors in the world today who still did this? I wish mine would help me out. The healthcare system in this country is very disappointing.

In any event, I will try once again with the state to try & get the denial reversed. I'm a stubborn PIA & don't take no as an answer very easily. I hope to find more time to post on the boards. I wish those who are still fighting luck & to those recovering, all the best on your recovery.
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----Karin----
Disc Bulge C4/C5, Disc Degeneration T11/T12, Bi-Lateral tears L5/S1, Diagnosed w/ Lumbar Disc Derangement w/ Radiculopaphy. Treatment: IDET, Percutaneous Discectomy, SI Joint Injection, Facet Block. All failed. Empire BC/BS Denied Coverage for ADR-lost all of my appeals. MVP also denied coverage.

ALIF/PLIF Fusion 1/20/09
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  #10  
Old 05-15-2007, 03:03 PM
ans ans is offline
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Karin,

I'm sorry that this has happened; you've been fighting for so long. I have the same insurance company too..

Good luck - Allan
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Severe, extensive DDD, considered inoperable by Dr. Regan, Lauressen, & some guy at UCLA. Severe foraminal stenosis (guess they can't operate!) and some spinal cord compression that Lauryssen would fix if gets outta hand.
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