Second appeal denied :(

[Paul]

Just went out and got the mail from yesterday and there it was. I am so down. I'm at loss as to what to do now. The year is almost up and I have been hearing rumors at work that next year we are going to an 80 / 20 type insurance program. Money is tight for me and if it gives approved next year I would never have the out of pocket for it. I'm thinking now of going the fusion route so I can get it in before the year is out. Can anyone tell me if this is a definite "death sentence" for my disk above? (I'm an L4 and L5).

The thing that really ticks me off about the insurance is the fossils they pull out to review your case. In my instance it was a Dr. Broock. UHC put in parentheses (Board Certified Orthopedic Surgeon) behind his name. A quick google search shows he is retired and specialized in arthritis patients. I think they put the parentheses in because in my dealings with my HR department I told them that UHC would do this.

Anyway, thanks for listening and if it's your persuausion send out a prayer my way.

Thanks,

Paul

paul im in the same boat appeal again if ya can.
let me guess BCBS?
chuck

[sahuaro]

What was the basis for the denial? cf Harrison's post re BCBS criteria.

[Harrison]

Sorry Paul. Last year, I had Blue Corpse Blue Sled (sorry, it makes me feel good to mock the company) and appealed all the way up until the day before surgery!

I received a "conditional approval" for coverage for my ADR procedure. In other words, my "deal" was that if ADR was approved in 2004 (which it was), BCBS would reimburse me for the costs.

Many people from this community have fought the beancounters and actuaries of the insurance world and won. Some of these successes are based on:

1. Tenacity & will power: Be prepared to make many phone calls, good note-taking with details, learning the appeals process of your insurance company. Once you make the decision, don't quit! Use every ounce of your resolve to do what's right for you.

2. Research: Scouring the archives here, and reading all the great suggestions (e.g. from Crystal, calling the Depuy # for appeal letters). And make sure you get real smart, real fast with your written health plan insurance policy.

3. Reciprocity: You know the insurance companies in mahogany row have highly paid lawyers, so get yourself one too. You may need it, and there are flaws in the BCBS policy. It's your lawyer's job to find them and exploit them to your humble advantage. As well, there are non-profits who specialize in patient advocacy from a legal perspective that can help.

It's unfortunate that lobbyists and their resultant gridlock have created a system that rations healthcare in a way that prevents choice. Do what's right for you...good luck.

[luvmysibe]

Hi Paul,
Please call the DePuy Spine Charite 1-800 # and request their appeals process handbook. It is free and has SO MANY SUGGESTIONS and LETTER FORMATS. I used this as my guideline when I appeal my case to the state board for workers' compensation and won. Please don't give up! We all understand your frustration, as most of us have had to put on the boxing gloves to win approval/reimbursement for our ADRs. Stay strong mentally, emotionally, spiritually, and physically. We are here to help with the journey!

[kristi]

If you really want to see red, I have further info about Dr. Gerald Jay Broock. I tracked him from California to Ohio and finally to Williamsburg, Virginia. According to the Virginia Board of Medicine, where all information is self reported, he updated his information June, 2005, and says his status is active. He reports that his practice is orthopedic surgery and he accepts no insurance and is not affiliated with any hospitals. Two numbers are listed in the white pages, but no one answers. I wonder if it is illegal to give false info to the Board.

You will probably also find that a couple of other doctors used by UHC to make decisions about your spine were a pediatrican and a doctor who specializes in internal medicine and diabetes. I really think the whole appeal process with UHC is just a farce.

Right now I am going to try to get some publicity since it's been almost one year since the FDA approval of the Charite. Have you tried the state Dept. of Insurance?
Good luck.

[Paul]

Thanks all. I did use the Depuy appeals guide. I sent them a stack of stuff about an inch thick. Articles, policies from other companies that are paying. It all boiled down to a gun-for-hire that has no soul who wouldn't know what a vertebra looked like if it jumped up and slapped him in the face. I'd be willing to bet at this point I know more about spine surgery than he does.

I'm not bitter or anything though.

Kristi, seems like our good doctor likes to donte to a certain political party (the sheister probably uses his fees from screwing people for this) and from this I know his address. I'm thinking of writing the good doctor a little note.

Thanks Harrison for the encouragement. I think my time is up though. Like I said after the first of the year when my insurance gets worse I won't be able to afford either type of surgery

[Karee]

God I sometimes wonder why any of carry ins. I just recently purchased a supplemental policy from UHC and also have bcbs thru my job, and it sounds like none of them want to pay unless you have the standard back fusion, I have already had one and never again - I firmly believe it is a road that just keeps going untill your back is one solid fusion - I am 66 years old and time is running out - I guess I just do not have the energy to fight all these ins. co. so will try to rake up the money to go to Germany

[luvmysibe]

When I began my quest for ADR approval, I became angered by and frustrated with the layers of red tape, lack of honesty, and conflicting nature of the insurance business. I am still awaiting payment from my supplemental insurance carrier; hopefully, they will follow through without too much of a hassle. It is disheartening to see how ligitimate cases of those in need of ADR are forced to fight because of those who attempt to cheat the system. Remain vigilant in your ADR convictions if you truly believe it is the best option for your situation. Best of luck to you all in your ADR quest!