How has anyone gotten insurance coverage

[cmarks927]

I'm having my surgery this friday, June 24th and have just been told that my insurance carrier (united healthcare) would approve the surgery, but not the disc. This doesn't make sense at all. Why would they cover surgery which is meant to put in the disc and then deny the cost of the disc. Now that ADR has been approved by the FDA, how can insurance companies deny it?

Has anyone had a similar issue? Did you get insurance to pay? If so, how?

Thanks. Cheryl

[rickz68]

Cheryl,

I have been fighting with my insurance (Health Net of California) for over a year to get my ADR surgery approved. So far I only know of three carriers that are approving it across the board, Aetna, Kaiser and BCBS of NJ. I have heard that UHC and Definity Health have been approving it on a case by case basis.

I don't know how any insurance company can deny coverage of the entire procedure since FDA approval defines the procedure as no longer being experimental/investigational.

Good luck.
Rick

[Dave]

Insurance companies are denying coverage because they can. There is no law, regulation, public outrage, media spotlight, nothing to "make" them pay...so they don't. It would appear we should just get used to it.

A nice long rant about special interests might be in order, but I'll save it. Suffice to say that the free market usually works best -- but simply never will when it comes to healtcare. It's hard to imagine what it will take for this to be understood in this country.

Dave

[Kim]

There are many of us here in the same boat. Either denied coverage or in the appeals process which I am in the middle of. I agree we need media coverage or legislation or something to make insurance companies sit up and take notice that they are not GOD and cannot pretend to be. Please note my earlier posts about contacting Montel etc. I highly encourage everyone to contact your senators and representatives and to contact all the big time media folks to let them know how many people this problem affects and how our insurance companies are denying us the health care that we need.
The squeaky wheel gets the grease
Some insurance companies are paying for ADR you can do a search and find out the ones that are approving at present. Good luck to you

[ans]

My insurance Empire Health Choice of NY said they'd pay for a two-level ADR but I didn't take them up on it. Good luck, ans

[Dave]

Great plan Kim. Glad to see a positive plan of action towards solving the problem. It helps temper my cynicism! I'll be writing those letters soon, and hoping others will jump on the bandwagon. The best thing that could happen would be a national media awareness of the situation. USA Today, Oprah, CNN, Time, etc. Maybe it really could work.

Dave

[paulam310]

cmarks, my insurance covered my surgery. I was told my the accounting department that they code the disk as a medical device (or something like that). I would question why the insurance company would be willing to pay the doctor to implant a disk, yet not pay for the disk. It doesn't make sense.

[Rein]

Cheryl

I think you need to contact the billing personnel of some of the surgeons who are successful in getting insurers to pay for the prosthetic. It could very well be a simple thing like delaying the surgery a week or two until the new billing codes for ADR prosthetics are in place (July 1st). I'd start with Dr. Delamarter's office in California, as he seems to have a higher success rate than most.

[paulam310]

Rein, I think that is a great idea. I just went to Delamarter's accounting office 2 days ago to pay for the balance of my surgery. They are very efficient and professional,they know what they are doing. I must say that he runs his office better than any other doctor I have worked with.

[letteski]

I spoke to Dr Delamarter's office this week and they said that the codes for the prodic was changing July 1st and gave me this code 0091T. There is no verbal description that she could give me. As a lay person not so sure what to do with it but share it here. Let me know if it helps anyone.