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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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Old 05-11-2005, 07:34 PM
sfmcfar sfmcfar is offline
Join Date: Apr 2005
Posts: 61

To my surprise (well, maybe not) MAMSI denied my coverage yesterday for a one-level ADR at L5-S1, stating that it's "unproven/experimental." They apparently have chosen to ignore the OPM regulation that clearly states that for Federal Employee Health Benefit plans, any FDA-approved drug, device or product cannot be deemed "experimental" or "investigational".

The appeal is already written and will be in the mail tomorrow. The appeal basically says that the FDA has approved Charite ADR, they're obligated to cover all FDA-approved procedures, so they either approve it or incur the wrath of the Federal Government for violating OPM regulations.

I really sympathize with those of you that are at the mercy of the insurance providers and that don't have any recourse for independent appeal...

L5-S1 DDD and herniation
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Old 05-11-2005, 10:09 PM
paulam310 paulam310 is offline
Senior Member
Join Date: Apr 2005
Posts: 121

Good for you Stan! FDA approval of the charite puts it out of the experimental category. Keep going till you get it.
3 level prodisc C4-5,C5-6,C6-7
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Old 05-12-2005, 06:03 AM
JoJo JoJo is offline
Join Date: May 2005
Posts: 47

I am at the external appeal phase myself. My appeal goes to the Insurance Department of my state. (NY) I'm faxing it today.

It's all just a delaying tactic. If they can put us off, some of us will die before they have to pay.

Good luck with your appeal!
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Old 05-12-2005, 11:58 AM
Senior Member
Join Date: Jan 2005
Posts: 128

I went thru 3 appeals and got a NO at each level, all taking over the posted amount of time
(15 days posted, 30-45+ actual for each appeal) in each letter UHC / my employer sent.

I have fusion of L5-S1 scheduled for this coming tuesday.

My Doctor did say the Orthopedic Specialist for UHC called him to discuss my case in the 2nd appeal phase, My doctor said that their Doctor had obviously been retired and out of the Mainstream for about 10 years, and already had an implanted NO in his head even before discusing ADR with him. For Every 10 good points they discussed the "specialist" just focused on the 1 negative point.

Oh well, Wish me luck.... I wish all of you the best in fighting the good cause.....
Greensboro, NC
Lost all ADR Appeals w/ UHC PLIF Fusion L5-S1 on 5/17/05.
Pars Defect L3-L4
DDD L3-L4 L4-L5
3 LVL Fusion Scheduled 4/08
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Old 05-12-2005, 07:14 PM
Harrison's Avatar
Harrison Harrison is offline
Join Date: Oct 2004
Posts: 6,938

Knock em dead, Stan! Or at least bowl them over with your eloquent, persuasive and governent-backed ammunition!

"Harrison" - info (at)
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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Old 05-13-2005, 11:48 PM
Kim Kim is offline
Senior Member
Join Date: Apr 2005
Posts: 267

Good luck and my best wishes to you! Prayers going up for a quick approval for you and go get em!
Herniated disc L5/S1 2000 Discectomy 10/2003 Rhizotomy 8/2004 and 3/2005Discogram 11/04 grade 7 tear L5/S1
L4/L5 Grade 5 tear with herniation and stenosis
Evaluated by Dr Blumenthal at TBI
2/2005 ADR 2 level recommended
2 level lumbar fusion
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