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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 05-20-2013, 11:51 AM
2Confused 2Confused is offline
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Join Date: Jun 2011
Posts: 322
Smile Insurance Paid - Dr. Clavel 2 level ADR

Hi all,

Its wonderful to have my life back! And I am excited to report that BCBS did PAY "out of network", which is 60% of the cost of my surgery with Dr. Clavel.
I honestly have no idea why or what we did any differently than anyone else. Possibly it was the documentation? or the fact that I have a Worldwide Blue rider on my policy.

We sent our documentation to Worldwide Blue the last week of Jan. 2013, by Fed EX with a signature required. We included a cover letter detailing my injury and the course of medical treatment and physical therapy that I partook in for the 3 1/2 years after the injury. In the letter we explained that the interim treatments were not working and that I along with my local neurosurgeon began looking for a solution. My Dr. Neuro's final diagnosis was for a two disc replacement (he uses the Pro-disc).
We explained that it was determined that a 2 disc replacement in a SINGLE surgery was best for my situation and that we also had determined that the M6 was best suited for me. (this was based upon our research, my Dr. had never heard of the M-6) We even stated that the M6 had not yet received FDA authorization, but was used successfully and routinely in Europe - specifically Spain- at a fraction of the cost for a single disc replacement in the USA.
We included detailed documentation of everything including a Letter of Medical Necessity from my local Neurosurgeon, copy of the auto accident report which was the cause of my neck problem, copies of paid invoices from BSC, detailed itemization of the total charges related to the surgery, proof of payment, medical reports, copies of x-rays, etc....
It also should be noted that I had 2 plus years of physical therapy, pain management, injections, chiropractor and had exhausted every conceivable alternative to surgery.

We are still in shock - can't believe that we were paid! It should be noted that it took more than 3 months for us to receive the check.

Hopefully, we will see more insurance companies pay for this in the future!

I do not know why they paid or what we did any differently from any one else who has attempted to be reimbursed by their insurance company so I really do not have answers. I will say KEEP DETAILED RECORDS OF EVERYTHING! I even requested copies of my doctor's notes for every visit (do this at the time of the visit as you check out) Also request copies of the radiologists reports for every x-ray, MRI, Myelogram, etc... I have a stack of documentation several inches thick. So keep copies of EVERYthing including hotel bills, dining, travel expenses, EVERYthing!

Hope this helps!
__________________
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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  #2  
Old 05-23-2013, 11:43 PM
Running11 Running11 is offline
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Join Date: Jan 2013
Posts: 187
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So happy for you!! I wish you a speedy and successful recovery. This is a very positive thing; having your insurance pay for what they are supose to!

Tammi
__________________
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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  #3  
Old 05-24-2013, 07:20 AM
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jss jss is offline
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Confused, I don't know what to say!?!? Congratulations!!!
__________________
C4/5 - ACDF in 2000
C5/6 - ACDF in 2002
C3/4 & C6/7 - M6 ADR, Nov 2009, Barcelona
Conceded defeat to a manifestly disingenuous BCBS-TX in my quest for reimbursement, Jan 2011
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  #4  
Old 05-24-2013, 08:38 AM
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TPatti TPatti is offline
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Posts: 491
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That is GREAT news!
__________________
*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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  #5  
Old 05-24-2013, 05:44 PM
SonjaB SonjaB is offline
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Posts: 69
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Wow, good for you! You're right in that the more receipts and documentation you have the better your chances of getting money for anything. Very hard when you are in pain though to think of everything so well done you.
__________________
60 y/o
2001 MRI L4/5 bulge/herniation, Nerve Block L5
2007 MRI L3/4 large hemorrhage L4/5 annular tear/bulge Nerve Block L4/5 Laminectomy L4/5
2008 MRI L4/5 annular tear
2009 MRI L3/4 extruded fragment/bulge/fibrosis/tear Laminectomy L3/4
2010 MRI L3/4 protrusion/extruded L4/5 bulge/protrusion
2011 MRI L3/4 bulge/annular fissure L4/5 bulge/annular fissure L5/S1 bulge
2012 MRI L3/4 protrusion L4/5 bulge Nerve Block L3/4/5
6/5/13 L3/L4/L5/S1 Dr Clavel NO MORE BACK PAIN
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  #6  
Old 05-24-2013, 07:21 PM
2Confused 2Confused is offline
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Posts: 322
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My wonderful spouse deserves most of the credit! He is great at keeping records and he encouraged me to keep a diary, notes and to get documentation from the doctors. But I really believe the documentation & having it organized probably had something to do with insurance paying... On that note I got my annual increase - UGH! It goes up 15 - 20% annually since the new Health Care Bill was passed.
Quote:
Originally Posted by SonjaB View Post
Wow, good for you! You're right in that the more receipts and documentation you have the better your chances of getting money for anything. Very hard when you are in pain though to think of everything so well done you.
__________________
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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  #7  
Old 08-09-2013, 02:17 PM
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herron65 herron65 is offline
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Join Date: May 2011
Posts: 67
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I had a simmular experiance with BCBS also. I submited it to Blue Card int. and it was approved and I was given 80% back in two checks fro some reason but hey its all good when you get money back and it also took about 6mo to get it. I thought for sure I wasent going to see a thing.
__________________
1992 Injured back two bulging discs at l4/5 &l5/s1
2002 microdisectomy at same level
January 2010 redo at level l4/5
November new MRI disc collapse at both levels
April 27 2011 M6 replacements at l4/5 & l5/s1 at Barcelona spine center with Dr Clavel.
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  #8  
Old 08-10-2013, 09:31 AM
Jerry5 Jerry5 is offline
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Join Date: May 2013
Posts: 363
Default Good for Both of you.

Glad to see that BCBS is now paying, if they want to stay in business, they have to go back to the books and realize, how to make money, how to pay for the injuries and make money while doing this or get out of the business altogether.

I have three more tests to take, in the coming weeks, all of it will be documented, as is everything else, even pain medication.

Good to see that the M6 really works, M6L, I emailed someone that had one put in at the L5-S1, four years ago, it really works, recommends it.

Again,

Glad for you Folks, still amazes me, that the FDA won't approve the M6.

Jerry
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  #9  
Old 08-10-2013, 10:56 AM
Jerry5 Jerry5 is offline
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Join Date: May 2013
Posts: 363
Default first test

First test this Tuesday, Facet block, don't like the idea of a needle in the back, but they will numb the site first.

Probably will feel good afterward.

J
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  #10  
Old 08-10-2013, 11:52 AM
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LauraB LauraB is offline
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Join Date: Jul 2013
Posts: 175
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I received a letter of non-certification from the "Medical Cost Management Corporation" for BCBS. I can't believe that they won't even consider fusion. Their "Principle Reason" is that my pain should be controlled with lifestyle changes and conservative treatment. They really want you to jump through hoops. Well since I'm the queen of record keeping, they will receive a 5 page letter outlining my "conservative" treatment along with doctors notes and results for the past 5 years. THIS THEY ALREADY HAVE! For goodness sake, BCBS paid for it! I have always been a firm believer that you never give up. These organizations rely on people throwing their hands in the air and saying, "oh well." Please let me know if there is anything else I can request or document while in Germany. I don't want to leave Dr. Bierstedt's office until I have whatever documentation, coding, etc. that can at least give me some chance of reimbursement; minuscule as it may be. I am elated to hear that many of you are being reimbursed, especially for multi-level. I am hopeful too. Congratulations for breaking the boundaries so the rest of us may pass!
My sincerest gratitude
__________________
2006 C 5/6 discectomy and fusion
2008 Automobile Accident
C3/4 leftward bulging of intervertebral disc mild narrowing of left lateral recess
C4/5 central and rightward bulging of disc and osteophyte causing mild right neural foramen stenosis narrowing and right lateral recess narrowing
C6/7 Central disc bulging and osteophyte and hypertrophy of ligamentum flavum canal stenosis and narrowing of bilateral neural foramina
Sept 9, 2013 Scheduled with Dr. Bierstedt C4/5 & C6/7 M6
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