ADRSupport Community  

Go Back   ADRSupport Community > General Discussion > Insurance Hell

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.


Reply
 
Thread Tools
  #1  
Old 07-23-2007, 06:24 PM
ZorroSF ZorroSF is offline
Senior Member
 
Join Date: Oct 2006
Posts: 303
Default

just received an email from Laurie todd about a successful ADR reversal.

Quote:
Houston, we have lift-off. The appeal that I have been working on with the gal in S.F. won, as of today. If I remember correctly, the surgery was denied at least twice.

Well, we overturned it. The insurer is Blue Cross/Blue Shield of California. My helpee wrote an elegant appeal, informed by the strategies.

If a person studies my book, then uses this appeal, tweaking it to make it their own, they should be able to have their own fine victory.

I have attached a copy of the appeal for all to use ... names changed, of course.


Victorious in Seattle,

Laurie Todd, I.W.
__________________
***********************
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
Reply With Quote
  #2  
Old 07-23-2007, 07:56 PM
Lisibug Lisibug is offline
Senior Member
 
Join Date: Apr 2007
Posts: 157
Default

I am going to try fighting Blue Shield using your outline - thanks so much for the advice, very well written appeal and kindness in sharing it with us! So glad you got reimbursed. I was turned down several times too, but I wasn't even allowed to see an ADR doc!
__________________
Lisa
Back/neck pain with chiropractic treatment 3 x week in 1973 (age 13) for 1 year and pain since then due to falling off horses
headaches since age 17
Onset of severe fibromyalgia in 6/95, undiagnosed for 2 years while lived in UK
About 1998 o
Reply With Quote
  #3  
Old 07-23-2007, 08:58 PM
Guest
 
Posts: n/a
Default

Hi Everyone,

My husband and I have used this appeal outline. Verdict is still out. My husband will be submitting the appeal tomorrow to our insurance and the president of his company. This is our second appeal.

I bought Laurie Todd's book and it is worth every penny. Regardless of the outcome it is a real eye opener.
Reply With Quote
  #4  
Old 07-23-2007, 09:09 PM
ZorroSF ZorroSF is offline
Senior Member
 
Join Date: Oct 2006
Posts: 303
Default

FYI

that is not my outline. that is what laurie sent out on her email list. feel free to use it.

Keep us posted if it works for you.
__________________
***********************
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
Reply With Quote
  #5  
Old 07-23-2007, 09:13 PM
Guest
 
Posts: n/a
Default

Actually, Laurie sent me this appeal after I purchased the book a few weeks ago. She has a wealth of information and my husband and I have exchanged several e-mails with her since I began the insurance process. I am looking forward to a response which I will have in 15 days. That being said, since my husband's company is self insured I am not sure who will make the final decision. Time will tell.
Reply With Quote
  #6  
Old 07-25-2007, 06:19 AM
Harrison's Avatar
Harrison Harrison is offline
Administrator
 
Join Date: Oct 2004
Posts: 6,909
Default

Indeed, good news from Laurie Todd and her ADR client! Great work!

That being said, I deleted the actual (edited for template) appeal, written by Laurie and her client, from Zorro's message. I don't care to help the people working AGAINST patients by giving them helpful insights into our battles against them! If you need it, simply email me - or Zorro.

__________________
"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
Reply With Quote
  #7  
Old 07-25-2007, 06:29 AM
Guest
 
Posts: n/a
Default

Harrison,

Good idea on the removing the appeal. I say buy the book for $14.95! It is well worth the money. Laurie Todd is a huge help if you have any questions.
Reply With Quote
  #8  
Old 07-27-2007, 05:23 PM
Abbe Abbe is offline
Member
 
Join Date: Feb 2007
Posts: 61
Default

I too have been in touch with Laurie. She sent me the outline and at first I didn't think I could use it in my case. But then I printed it out and was able to edit, add, delete various parts of the appeal and then in the end I was able to modify it enough to pertain to my case. I sent mine out on the 25th of this month so, we will see. My insurance company Motion Picture Industry, Blue Shield, Ca. Department of insurance should all have it by Monday the latest. Hope it works for me. The insurance company denied me 3 times and most likely thought they were done with me back in April. They stated the only other thing I could do is sue them in federal court. We will see....

Abbe
__________________
Water ski accident 86'
Chiropractic& PT Pain meds
Discectomy Laminectomy
L5 S1 Partially sacralized
97' epidural injections
L3 L4 ruptured and torn
L4 L5 Almost no disk height left along with osteophytes
Left leg pain and tingling going down back of leg into heel & foot
3 appeals with BCBS no success Lost insurance.
Kaiser Permanente
L3-L4, L4-L5 Prodisc 9/18/09
C5-6 & C6-7 ruptured and looking at hybrid surgery fusion & Prestige ADR
Reply With Quote
  #9  
Old 08-28-2007, 02:30 PM
Guest
 
Posts: n/a
Default

Hi! I am brand new to this community so I am not sure whether I am requesting this info properly or not, but could the author of the message Re: victorious appeal against BC/BS e mail me the strategy used? I don't seem to have a chance against my BC/BS insurer. I am one of the few who needs both ALIF at L5-s1 & ADR at L4-L5. Have been in pain for two years and I really need surgery!!! Any advice would be appreciated. Please send to l5-s1@hotmail.com. Thank you kindly!!!!
Reply With Quote
  #10  
Old 07-26-2010, 09:25 PM
Abarco Abarco is offline
Junior Member
 
Join Date: Jul 2010
Posts: 9
Question TriWest ADR Denial

Hello Everyone I am new to this Forum and was wondering if anyone has been approved for a cervical ADR... I received my denial yesterday and sent thid email below as a request for medical review reconsideration..

26 July 2010
TriWest Health Care Alliance
Reconsideration Department
PO BOX 86508
Phoenix, AZ 85080




To Whom it May Concern:

I am writing to request a formal appeal of the rejected proposed
treatment, cervical disc arthroplasty, for the following diagnosis:
* Cervical Disc Degeneration
* Chronic pain to neck and to right scapular region
* Chronic Muscle spasms to neck and to right scapular region
* Nerve Palsy to right upper shoulder and arm
* Cervical Radiculopathy
* Spondyloarthropaty of cervical spine
* Loss of normal lordotic curvatrure of the cervical spine
* Mild disc desiccation
* Headaches
All of my above listed medical diagnosis are documented with associated
numerous tests that I have been put through since approximately 2007.
Sadly, I have attempted and failed numerous rounds of conservative
treatment only to live in constant pain and always scared and guarded to
not have an acute spasm which feels like I have been struck by lightning
in the back of my neck. This is also affecting my career because of the
numerous medications and vigorous expectations that are demanded by my
profession. I can no longer work as an emergency-trauma Registered
Nurse Specialist. I am currently in graduate school for Acute Care
Nurse Practitioner but with my chronic neck problems this could shatter
my dream, as well. At my age a fusion would literally put me on the
"bench" forever. I have three young children that I would love to
conquer adventures with. With a fusion there would be serious
limitations. I have tried soft c-collars, trigger point injections,
Chinese acupressure, Chinese acupuncture, cupping, tens-unit, moist
heat, cold therapy, cervical pillows, tempur-pedic bed, physical
therapy, professional massage, chiropractic adjustments, freezing and
stretching with ethyl chloride, prednisone, NSAIDS, narcotics, lyrica,
neurontin, muscle relaxers, the Felix trigger point board, cervical
epidural injections, facet injections and ultra sound therapy. I have
literally spent thousands of dollars and have exhausted every possible
remedy to relieve this horrible condition so that I can start living my
life like I used to. Dr. Briggs, my neurosurgeon from the Springfield
Neurological and Spine Institute, Dr. M. Akhtar Choudhary (my
neurologist) and I have all agreed that the cervical disc arthroplasty
is the most appropriate treatment for my condition and that I DO meet
criteria for disc arthroplasty and should undergo this surgical
procedure. Please find the attached documentation that may be helpful
in your
reconsideration of the pre-authorization claim for benefits and payments
in which Tri-Care does cover for all Active Duty Soldiers, but is sadly
denying their dependants of this medical necessity:
* A copy of "not approved" letter
* Medical Justifications for cervical disc arthroplasty
* Clinical literature on disc arthroplasty
* A letter from my doctor
* Cost benefit analysis reports
* FDA approval letter for the prestige ADR

Thank you for your consideration of this much needed coverage . If there
are any questions please contact me at 573-847-8246

Angela M. Barco RN, BSN
Reply With Quote
Reply

Bookmarks

Tags
adr insurance appeal, artificial disc replacement appeal, insurance appeal, spinal arthroplasty coverage

Thread Tools

Posting Rules
You may not post new threads
You may not post replies
You may not post attachments
You may not edit your posts

BB code is On
Smilies are On
[IMG] code is On
HTML code is Off


Similar Threads
Thread Thread Starter Forum Replies Last Post
Blue Cross Blue Shield {aka Blue Crap} chasswen Insurance Hell 16 06-06-2012 06:03 PM
Blue Cross Blue Shield ADR Coverage stuschulz Insurance Hell 10 09-24-2007 10:54 AM
Technology Evaluation Center Blue Cross Blue Shield Abbe Insurance Hell 2 07-03-2007 08:30 PM
Federal Blue Cross Blue Shield misty The Big File 6 04-05-2005 12:34 AM
3rd Appeal with Blue Cross Blue Shield cavalier The Big File 10 03-25-2005 11:24 AM


All times are GMT -4. The time now is 01:37 PM.


© Copyright 2006-2017 ADRSupport.org All rights reserved.