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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.


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  #1  
Old 01-16-2013, 12:52 PM
Running11 Running11 is offline
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Join Date: Jan 2013
Posts: 187
Default Anyone get ADR covered by BC/BS

Has anyone successful got coverage from Blue Cross/ Blue Shield? If so can you please tell me your name , doctor, procedure and date of coverage.

I am preparing an appeal for a 2 level ADR in my cervical spine. Of course , they have denied coverage deeming the surgery; "investigation" and "unsafe"

Thank you so much. You can respond to this thread or send me an email privately.

We have to stick together and not take no for an answer!
__________________
disc bulges C 4-5 and C 5-6
EMG evidence nerve root blockage at C6, C8 and L5
Cogential moderate-severe cervical/lumbar stenosis
Cervical compression with clinical myelopathy with Hoffman's
Tests; MRI's, EMG/NC studies, discogram, CT scan
Pain management; tens unit, ice and heat, physical therapy, chiropratic care, and spinal epidural treatments.
Blue Cross / Blue Shield of Ohio external third party approved Pro-C ADR at C 5-6 on 4/3/13
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  #2  
Old 02-05-2013, 02:56 AM
Slackwater Slackwater is offline
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Join Date: Aug 2007
Posts: 782
Default

Quote:
Originally Posted by Running11 View Post
Has anyone successful got coverage from Blue Cross/ Blue Shield? If so can you please tell me your name , doctor, procedure and date of coverage.

I am preparing an appeal for a 2 level ADR in my cervical spine. Of course , they have denied coverage deeming the surgery; "investigation" and "unsafe"

Thank you so much. You can respond to this thread or send me an email privately.

We have to stick together and not take no for an answer!
Revised January 15, 2013
BCBSF Medical Policies (Medical Coverage Guidelines)

Blue Cross Blue Shield Coverage Position above.

See your provider and find the "Coverage Position". It appears to be 1 level in Florida.

The question to ask is if the proposed surgeon in BCBS has done the training and how many ADR/TDR operations have been performed, post-surgery NDI at 6 and 12 months for how many patients.
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  #3  
Old 03-20-2013, 11:28 PM
Stircrazie's Avatar
Stircrazie Stircrazie is offline
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Join Date: Nov 2011
Posts: 62
Default Check out this thread.

http://www.adrsupport.org/forums/f43...dvocate-11305/

The advocates are a great help. I did not need it though. My surgeon fought the fights for me. All I had to do is go through the tests requested.
__________________
Shawn in Wisconsin
36 YO
2007 DDD L5S1
2007-2010
7 Inj and PT
2011 2 Inj.
Aug. Inj did not help at all. MRI.
XRay neg. Sept MRI
Discogram L5S1 pain was 10 of 10. L4L5 pain was 2-3.
DR advised me about ADR. Ins Approved after appeal.
Surg 12/16 Xmas gift!
Feeling GREAT!
http://www.facebook.com/Stircrazie
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  #4  
Old 03-24-2013, 01:22 PM
Running11 Running11 is offline
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Posts: 187
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I called an advocacy and they said they couldn't help me. They said doing a cervical 2-level ADR was off label. That two level hasn't been FDA approved. What kind of baloney is that ? How long has Dr. Clavel been doing more than 1 level? The FDA in America act like they are protecting the consumer and patient but what their really doing is hurting us and leaving us out in the cold in pain . They really seem to protect the insurance companies ..
__________________
disc bulges C 4-5 and C 5-6
EMG evidence nerve root blockage at C6, C8 and L5
Cogential moderate-severe cervical/lumbar stenosis
Cervical compression with clinical myelopathy with Hoffman's
Tests; MRI's, EMG/NC studies, discogram, CT scan
Pain management; tens unit, ice and heat, physical therapy, chiropratic care, and spinal epidural treatments.
Blue Cross / Blue Shield of Ohio external third party approved Pro-C ADR at C 5-6 on 4/3/13
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  #5  
Old 03-25-2013, 11:27 AM
2Confused 2Confused is offline
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Join Date: Jun 2011
Posts: 322
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Running

I have BCBS & I applied for reimbursement with Worldwide Blue, the international rider on my policy. It has been approx. 6 - 8 weeks & so far the only thing I have heard is that "it is under review" and they gave me a claim number. Will keep you posted.

I had two level ADR with Dr. Clavel in Oct. 2012. I think everyone should file a claim with their insurance company & fight for coverage. I may not get reimbursed, but I am going to battle!
__________________
50 year old female
Rear-Ended in 2009
Disk rupture cervical 5-6 & 6-7
2 level M6 ADR, Dr. Clavel - Oct. 2012
Insurance paid
Not a day goes by that without me whispering a silent "thank you" to Dr. Clavel
Post Op 2+ years
Cross Fit 3-5 times a week
Running 5ks
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  #6  
Old 03-25-2013, 09:50 PM
krossi201 krossi201 is offline
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Join Date: Jan 2013
Posts: 28
Talking

Soon the mobi- C will be approved for two level cervical ADR in US. The FDA estimates late summer 2013 for full approval. This may help with insurance appeals!
__________________
C4/5 and C5/6 broad based posterior herniations with effacement since 3/2012.
Radiculopathy and Myelopathy with positive Hoffmans.
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  #7  
Old 03-26-2013, 05:29 PM
newleaseonlife newleaseonlife is offline
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Join Date: Nov 2012
Posts: 101
Default

Quote:
Originally Posted by 2Confused View Post
Running

I have BCBS & I applied for reimbursement with Worldwide Blue, the international rider on my policy. It has been approx. 6 - 8 weeks & so far the only thing I have heard is that "it is under review" and they gave me a claim number. Will keep you posted.

I had two level ADR with Dr. Clavel in Oct. 2012. I think everyone should file a claim with their insurance company & fight for coverage. I may not get reimbursed, but I am going to battle!
I too have BCBS and filed a claim recently. I doubt anything will come of it, but if it makes the insurance people take a second look at adr vs. Fusion then it will be worth it.
__________________
02/2010- Car accident resulting in C4/C5 & L5/S1 bulging and extruding discs.

06/2012- Successful ADR surgery for C4/C5 disc in Cyprus using PCM by NuVasive. Performed by Dr. Mark Peterson through the help of AIMIS.

09/2012- Successful Disctectomy of L5/S1also performed by Dr. Mark Peterson.
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  #8  
Old 06-29-2013, 10:07 AM
Jerry5 Jerry5 is offline
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Join Date: May 2013
Posts: 363
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I have BCBS, Ohio, and they approved the MRI, follow up, the VA paid for my L2-L3 discectomy, but I believe it is failing, this happened two days before Thanksgiving, and I had the L2-3 done on 3/29.

I talked to the Dr, and we agreed to a 3 level, replaced the damaged one, l2-l3, then replace the two lowest, l4-5 and L5-S1, that is the worst one, I have severe stenosis, the lower two are almost fusing, I will see the results of the contrast MRI and see what is going on for sure,

I will let people know what BCBS does, I am sure they will fight this.

Jerry
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  #9  
Old 07-01-2013, 11:51 PM
Running11 Running11 is offline
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Join Date: Jan 2013
Posts: 187
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Jerry,

I have BC /BS. Going from my experience they will pay for ONE and ONE only.
I went through first, second and external appeals. My surgeon put in for two. They approved one and the one that was the better of the two. What morans.

Even though they only paid for one of mine maybe they'll pay for yours. There's always hope. I had a cervical compression and severe stenosis with three nerve roots compressed. I went through all testing and results were all positive . BC/BS ignored my testing results or didn't read my results and I fought them for a year. I am considering suing them for damages because I have permanent nerve damage in my hands.

My advice to you; don't give up, fight them like h--- kicking and screaming for your life. Don't take no for an answer or listen to any naysayers. They have to start paying! Good luck keep me posted!
__________________
disc bulges C 4-5 and C 5-6
EMG evidence nerve root blockage at C6, C8 and L5
Cogential moderate-severe cervical/lumbar stenosis
Cervical compression with clinical myelopathy with Hoffman's
Tests; MRI's, EMG/NC studies, discogram, CT scan
Pain management; tens unit, ice and heat, physical therapy, chiropratic care, and spinal epidural treatments.
Blue Cross / Blue Shield of Ohio external third party approved Pro-C ADR at C 5-6 on 4/3/13
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  #10  
Old 07-04-2013, 08:13 AM
Jerry5 Jerry5 is offline
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Join Date: May 2013
Posts: 363
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Running,

I had a discectomy, at the L2-3 level already, it helped with the pressure on the back, at the site, but these operations need to be resolved in a few days, not weeks or even months(I have numbness in the leg, sensation, lateral femoral, this is a result of 'waiting'), it took 4 months to get that one, and now I am looking at the L5-S1, L4-5, and the L2-3.

There are cases where the whole cervical neck was done, something like 6 or 7 levels.

Disc Replacement Surgery cost and details, Artificial disc replacement surgery.

This has the costs, two level, including flight and aftercare is about $40,000 US.

http://www.germanspinespecialists.com/press.html is another one in Germany.

Both of have done multi-level with the M6.
(Spinal Kinetics)

By the time that the US Insurance Company fights this and pays for optional treatments, they will spend more than twice this.

Silly.

With this technology, developed by NeuroSurgeons here in the USA, California, really has to make one wonder, why not approve this for the states.


I had follow up MRI and XRays this week, the first actually, and will see the DR again on Monday the 8th.

One blow out is enough, I cannot afford another back problem like that, I have been on Meds for EIGHT months, this is ridiculous.

Going for ALL 3.

Be done with it.

More Later.

Happy 4th.


Jerry

Last edited by Jerry5; 07-04-2013 at 08:41 AM. Reason: grammar
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