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  #1  
Old 04-26-2005, 01:20 PM
Juli Juli is offline
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Has anyone submitted a pre-authorization request to their insurance on their own or have they all been submitted by U.S. Docs? I am fairly sure that I am going to have to pay for my ADR myself, but have not yet seen a U.S. Doc that has recommended it. My current doctor is saying fusion, that two level or more is not being done yet in the states, sigh.

I sent my records (acutally, Mark did via the ***) to Dr. Zeegars in Munich and Dr. Bitan in New York and Dr. Zeegars called me and emailed me the next business day. He said at first look I will probably need my L3-L4 done and possibly one more but he will not know for sure until he does the test. This surprised me as my L4-L5 and L5-S1 look much worse to my uneducated eyes. He also said it is possible another procedure can be done to resolve the problem if the L3/L4 is the only one causing the problem. He said I did not look like a good candidate for fusion, some people are actually good candidates for that process, he says.
I have not heard from Dr. Bitan yet but it has only been a few days.

My thought is to travel to Munich and just have the tests done and then submit that diagnosis to my insurance company and see how it goes from there. I thought if I had a clear and specific procedure that it would be easier to argue the case. ( I can dream right?)

I did call my insurance company UHC, and they said that I can have surgery overseas, but I would have be at the out of network rate, of course.

Does anyone have any experience with this specific process or any other suggestions?

Thanks, as always, for the great forum!
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Juli
DDD L3-L4 on down since 1990
Surgery 9/26/05 with Dr. Bitan in NYC to complete partial congenital fusion of L5-S1 and ADR at L3-L4 and L4-5.

Feeling great!
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  #2  
Old 04-26-2005, 03:38 PM
bmills bmills is offline
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Juli, multi levels have been and are being done here in the states. At Texas Back Institute and several other places. I know two doctors in my area that do them.

If you want more info let me know.

Brady
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15+ yrs chronic low back pain.
L5/S1 DDD
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  #3  
Old 04-26-2005, 04:01 PM
Juli Juli is offline
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I know! The sigh was for, see what we have to deal with!

My questions are:

Has anyone sent an pre-auth form directly to an insurance company themselves?

Has anyone got UHC to pay for this procedure yet? I am pretty sure I am going to have to pay for it.

And, has anyone tried to get the diagnosis overseas first, like I am going to try, and then try to get a pre-auth before they actually do the surgery?

I am assuming that my insurance isn't going to pay for it, therefore, I plan on having the surgery done in Europe. But, I am certainly going to fight the fight!

Thanks!
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Juli
DDD L3-L4 on down since 1990
Surgery 9/26/05 with Dr. Bitan in NYC to complete partial congenital fusion of L5-S1 and ADR at L3-L4 and L4-5.

Feeling great!
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  #4  
Old 04-27-2005, 04:41 PM
Paul Paul is offline
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I just received my denial letter from UHC last Friday. My doctor (TBI) sent in all the information. They did tell me it was sent to pre-determination rather than pre-certification. unsure what the difference is but there must be one because they stressed that to me a few times.

Last time I went to the doc (about a month and a half ago) they told me they did have someone approved by UHC. That gave me some hope until I got the denial. Would be nice to know who it was so I could use as ammo.
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  #5  
Old 04-27-2005, 05:00 PM
APS APS is offline
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Paul,
Curious - Is your UHC plan an HMO or PPO?
I recall someone on here was approved by UHC also.
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Andrea
Grand Junction/Denver, CO

Failed L4-5 diskectomies '93 & '00
ADR originally scheduled 3/9/05; dropped insurance appeal due to new job; new insurance UHC
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  #6  
Old 04-28-2005, 07:19 AM
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If you can cover the cash outlay for 3-6 months and you won't loose your house if they don't pay then you can try this. Ins. has some strange rules but they may work in your favor. Read your policy rules on how many planned days you can stay in the hospital before you need their pre-cert. My policy said 3 or more scheduled days in the hospital required pre-cert. Most ADR patients can be out in 2 days. Don't plan on driving home then, just get a hotel room near the hospital and stay till your first follow up.


Tell the hospital you want a cash package price for your planned 2 day stay since you are having to pay for it all yourself. Don't let on you are going to submit for reimbursment after surgery. You should be able to get a single level done for $35-$45,000. If the come back with $60-80,000 tell them you have been looking into going to Germany for under $35,000. If they are having problems getting insurance to pay or pre-cert others they will jump at the chance for a cash customer. Your Dr. office may also not know how to handle cash customers. If they don't, ask if they have an international patients dept. They will know how to get you a package deal.

After surgery request an itemized list of all your charges with ins. codes and then submit this to you ins. co. You can try to get the hospital to submit for you, but they sometimes won't do it for package deals. I don't think your ins. can or will deny an FDA approved procedure. If they do try to deny it then call your states insurance commisioner and tell them you have followed all your ins. co. rules for this FDA approved procedure and they won't reimburse you.


Good Luck and work the system to your advantage.

Pat
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  #7  
Old 04-28-2005, 10:25 AM
NCFUSED NCFUSED is offline
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Paul, I lost both appeals to UHC....my company is self insured so their appeals committee is my last hope......
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John
Greensboro, NC
DDD L5-S1
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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  #8  
Old 04-28-2005, 11:23 AM
Juli Juli is offline
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This is what UHC says on their website, this may just be for the plan my company has, I am not sure.

"Before you or your covered dependents have Surgery - Call UnitedHealthcare's Member Services.
Having surgery is a big step. In many instances, you can avoid unnecessary surgery by getting a second surgical opinion. If you do have a second opinion, it will be covered under your chosen health plan option, subject to the appropriate deductible and Coinsurance amount"

I then called and she said a pre-auth should be submitted prior to any scheduled in patient surgery.


One other interesting note, I found on their website is regarding foreign claims. They state to try to get a bill in english and U.S. Dollars, but if you can't, do not translate them yourself, that UHC will provide the translation services.
__________________
Juli
DDD L3-L4 on down since 1990
Surgery 9/26/05 with Dr. Bitan in NYC to complete partial congenital fusion of L5-S1 and ADR at L3-L4 and L4-5.

Feeling great!
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  #9  
Old 04-28-2005, 12:11 PM
NCFUSED NCFUSED is offline
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My doctor's Billing person told me in no way to call UHC for pre-authorization myself. To let them handle it. But when it came to the appeals, I was on my own......
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John
Greensboro, NC
DDD L5-S1
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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  #10  
Old 04-28-2005, 03:10 PM
Juli Juli is offline
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Hi John,

Yes, the UHC rep told me the doctor should submit. I do not know if that means it HAS to come from the doctor. I am not sure if an overseas doctor would submit it for me. I guess I will have to call them back.

Each answer begats more questions!
__________________
Juli
DDD L3-L4 on down since 1990
Surgery 9/26/05 with Dr. Bitan in NYC to complete partial congenital fusion of L5-S1 and ADR at L3-L4 and L4-5.

Feeling great!
Reply With Quote
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