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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 06-06-2013, 01:03 PM
VegasGuy13 VegasGuy13 is offline
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Default ADR Surgery Done, Waiting for Denial.

Hello everyone. I have BCBS as my insurer under the federal employee program. I am retired. My primary physician put me through all the paces before referring me to Dr. Kenneth Light in San Francisco, who is one of the best spinal surgeons in the Bay Area. Dr. Light reviewed my MRI and x-rays and urged me to choose the ADR choice rather than a fusion and explained all the advantages of the ADR and disadvantages of the fusion. It was a no-brainer. He went ahead and tried to get an approval from BCBS and of course they denied it as investigational. Due to my condition, we went ahead with the surgery, which I paid for out of pocket. We are now submitting the claim and expect a denial from BCBS. I really appreciate this forum and look forward to your help with my case as it develops.
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  #2  
Old 06-06-2013, 01:16 PM
NJ Gene NJ Gene is offline
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Hi Vegas Guy,

For whatever it is worth, I've been told that in most cases BC/BS will not pre-authorize ADR. However, I know of people who have been told this regarding surgeons in Europe and were in fact paid after the fact. If your surgery was done in the U.S. under FDA guidelines (it sounds like it was) I believe you have a good chance of ultimately getting reimbursed. It may take a couple rounds of appeals, but I think you have a chance, especially if your surgeon is willing to assist you during this process.

The most important thing is that you had the surgery done and are doing well.

Gene
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Car Accident 2002 - Small Herniated Disc C3/C4
1998 Larger Herniation and Cervical Fusion C3/C4
2005 Herniation C4/C5 - 40 epidural steroid injections from Oct 2005, - Oct, 2007
2008 - Foraminotomy at C6/C7 on left side
Feb, 2010 - Cervical Fusion C4/C5
Dec, 2010 - Lumbar Fusion L3/L5
2013 - Bulge on C5/C6; herniation C6/C7 right side
Mar 26, 2013 - Foraminotomy at C6/C7 on right side
May 5, 2015 - ADR with Dr Blumenthal of TBI for C5/C6 using Mobi-C
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  #3  
Old 06-06-2013, 08:14 PM
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Grover771 Grover771 is offline
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Hi Vegas Guy,
first, congratulations! I'm very jealous, as I've just scheduled my surgery date for July. I also have BC/BS and will be fighting for reimbursement. Can you tell e which level? Lumbar or cervical? One level or more?

When was your surgery and how are you feeling?

Congrats again and I hope you're feeling the relief we are all begging for.
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Deb
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1988 diagnosed with DDD, bulging
2012 trauma lumbar following yard work
Nov 2012 MRI Bulging discs L4,5, S1
Mild stenosis
Dec-Jan PT
Jan 2013 Discogram
Results Level 5 Annular tears L3-4, L4-5 and L5-S1
Need 3 disc fusion
Facet Joints injections, March 2013- no relief
Transform.., Epidural Injections 4-23-13 Right L2-3 No relief
2nd ESI 5-14-13 L3-4, L4-5, L5-S1 No relief ugh.
ADR L3-4, L4-5, Fusion L5-S1 Fusion Dr.Blumenthal TBI July, 2013
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Old 06-06-2013, 09:29 PM
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Harrison Harrison is offline
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Just a reminder that some patients are getting BCBS to pay, even overseas. Maybe most of these happen because they have the special international coverage. Still others have appealed and won. People with some $ hire lawyers are often successful.
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  #5  
Old 06-10-2013, 01:08 AM
VegasGuy13 VegasGuy13 is offline
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Quote:
Originally Posted by Grover771 View Post
Hi Vegas Guy,
first, congratulations! I'm very jealous, as I've just scheduled my surgery date for July. I also have BC/BS and will be fighting for reimbursement. Can you tell e which level? Lumbar or cervical? One level or more?

When was your surgery and how are you feeling?

Congrats again and I hope you're feeling the relief we are all begging for.
Hi and thanks. It was C5/6 which I hear is the most common. Because I had to pay for the surgery, the surgery was done in a Surgery Center rather than a hospital, which saved big bucks. I spent the night and had to be discharged in exactly 23 hours to keep it an outpatient surgery. No complications. Pain has reduced immensely but not yet totally. Good luck to you. Let us know how you do.
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Old 06-10-2013, 01:10 AM
VegasGuy13 VegasGuy13 is offline
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Thanks, very encouraging. I appreciate the supportive comments.
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  #7  
Old 06-11-2013, 04:08 AM
kimmers kimmers is offline
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Vegasguy,

I know in the past, people with federal insurance through BCBS got their appeal overturned. It has to be due to federal law and FDA approval. There are people who got reimbursed and even preapproved. Go back five years or so, that is when I talked to one of the persons who was successful.

K
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  #8  
Old 06-17-2013, 12:56 AM
VegasGuy13 VegasGuy13 is offline
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Default Federal overturn

Thanks for the information. I would hope there is a reference out there somewhere that alludes to Federal employees being approved for a procedure if the FDA has approved it.
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  #9  
Old 06-18-2013, 01:38 AM
Running11 Running11 is offline
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Vegas-guy,

I had my ADR with Dr .Light also. He's the best. I also have BC /BS; they are the worst. I went through Two levels of appeal and then an external reviewer said they HAD pay. They had such a tantrum my bill was 135,000 and they only paid 35,0000 of the total bill. What a joke. They paid so little and made such a stink.

I know for me it took constant calling almost on a daily basis. Make sure they have ALL your medical records; tests , any doctor's seen , physical therapy , chiropractor care, medications taken and steroid injections, everything you have tried and failed. (MRIs , EMG/NG results; I THINK THESE WERE THE ONLY DATA viewed by BC /BS ; the EMG's. I have not a clue why.

What is the latest update?

How are you feeling?

Good luck and keep me posted. Feel free to PM me .

Tammi






Tammi
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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 06-18-2013, 06:33 AM
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TPatti TPatti is offline
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Were you responsible for the other $100,000.00?
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*9/10: Unstable pelvis & SI joint, sore IT band. Chiro care, I would shift out hours to days after adjust
*12/10: PT & chiro
*4/11 to 11/11: 5 sessions prolo and 3 prolo w/ PRP
*12/28/11 ESI L L4/L5 - 1/13/12 ESI R L4/L5 - 1/24/12 L SI joint capsule - 3/8/12 TPI - 3/23/12 L L5/S1 - 4/11/12 ESI caudal - 5/23/12 TPI - 7/10/12 Facet inj L3/L4, L4/L5, L5/S1
*9/12/12: 30 - DRX9000
*12/21/12 schedule. for L4/L5 fusion-CANCELLED 1/7/13
*7/16/2013: 3 level M6(S1-L3) w/ Dr. Bierstedt
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