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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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  #11  
Old 06-18-2013, 08:30 AM
Jen93312 Jen93312 is offline
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Join Date: Aug 2011
Posts: 87
Default Blue Cross/Blue Shield

Uggh! My insurance will change in a few weeks to BCBS of Texas. They have a buy-up plan & I'm hoping the international option is included. L
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Jen
C3 Bulge
C4 Bulge
C5 ruptured
C6 Bulge
7/2011 epidural that caused a "fragment to present itself"
10/2011 C5-C6 Foraminotomy & removal of fragment
Positive for left-sided Hoffman's reflex
Effacement of anterior spinal artery
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  #12  
Old 06-25-2013, 06:20 PM
kimmers kimmers is offline
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Join Date: Jan 2008
Posts: 554
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Quote:
Originally Posted by VegasGuy13 View Post
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.
Vegasguy,

I looked up some information I have in my last appeal to BC. It was not BC who paid but the person (I think it was treefrog) sent me a copy of the approval letter from her insurance, Coventry Health Care, which I put in my appeal.
She was a federal employee and this is part of what the letter says:

Our Medical Director has reviewed the information submitted to include, but not limited to, letter of medical necessity, cost estimate of insurance, patient pre-evaluation questionnaire, and Plan language. The predetermination request was elevated to our Medical Director, Floyd Shewmake, MD, for consideration. Dr. S reviewed the prior determination made by our Medical Director Debra Esser, MD, and overturned her decision. He states that the Federal Employees Health Benefits (FEHB) Plan cannot deny the artificial disc as experimental/investigational if it has been approved by the FDA (Food and Drug Administration). Therefore, we are able to approve the artificial disc placement surgery as medically necessary under the Plan's contract of benefits.

this letter was dated April 23, 2009 and was to Dr. Rudolph Bertagnoli in Bogen Germany.

This is why I do not believe that an insurance company can deny any federal employee anything that is FDA approved. So keep trying, chances are you will succeed.
As for material for my appeal, I found it difficult to receive actual approval letters as people worry about the insurance companies' power to take back an approval or money. With a lot of digging, I actually got a lot of information. BTW, the lady who gave me this letter lives in South Carolina and I am sure, she would probably give you a copy if you find her on here.

Happy hunting,

Kimmers
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hurt back lifting, herniated disc at L4/L5. DDD
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  #13  
Old 06-25-2013, 06:29 PM
kimmers kimmers is offline
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Join Date: Jan 2008
Posts: 554
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Hey Vegas,

I am not completely sure it was treefrog as it has been a few years. If you can get a hold of her, however, she has a lot of info about ADRs and Slackwater does too.

K
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hurt back lifting, herniated disc at L4/L5. DDD
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  #14  
Old 09-18-2013, 09:23 PM
tidebiz tidebiz is offline
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Join Date: Sep 2013
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Quote:
Originally Posted by VegasGuy13 View Post
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.
VegasGuy - Do you recall what your surgeon charged, and what the surgery center charged, for your 23 hour stay C5-6 arthroplasty? Many thanks,
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  #15  
Old 09-19-2013, 04:55 PM
2Confused 2Confused is offline
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Join Date: Jun 2011
Posts: 322
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Vegas Guy,

BCBS paid for my two level ADR (60%) and I had the surgery overseas. Submit a claim and appeal them if they do not pay. Also, I just read recently that the FDA has now approved 2 level ADR Cervical surgery. That should help you with the claim. Hope you are doing well.
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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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  #16  
Old 11-29-2013, 07:57 PM
bwink23 bwink23 is offline
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Join Date: Nov 2013
Posts: 262
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2Confused.....are you a federal employee?
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2013 - MRI and CT scan....DDD L4-S1
left side (where my pain is) interarticularis pars fracture/defect with Spondylolithesis L5 over S1 with 2MM anterior displacement

Feb. 2014 - Hybrid lumbar fusion(l5/S1), ADR(L4/L5)...2-level cervical ADR (C5/C6, C6/C7). Dr. Pablo Clavel of Quiron Hospital in Barcelona, Spain. All M6 implants (PEEK cage and plate from Medtronic at fusion level in lumbar.) SAME DAY OPERATION for both areas of the spine.
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  #17  
Old 12-02-2013, 01:14 AM
VegasGuy13 VegasGuy13 is offline
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Join Date: May 2013
Posts: 13
Default Federal Employee

I am a retired Federal Employee.
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  #18  
Old 12-02-2013, 02:04 AM
Running11 Running11 is offline
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Join Date: Jan 2013
Posts: 187
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No , I wasn't because BC/ BS is contracted with hospitals to pay only a certain fee . They charge people like you and I a super bill rate. Since , I was approved through the third level of appeals BC/ BS payed their contracted rate. I don't understand his all this works but if your insurance covers you 100 percent based on plan. Everyones plan is different and the amount they are required to pay. Example , meeting deductibles. Just because I didn't have to pay the rest doesn't mean yours will cover it too.
__________________
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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  #19  
Old 12-05-2013, 12:39 AM
2Confused 2Confused is offline
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Posts: 322
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Quote:
Originally Posted by bwink23 View Post
2Confused.....are you a federal employee?
No I am self Employed, so I have an individual policy through BCBS.
__________________
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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  #20  
Old 12-08-2013, 06:36 PM
FranklySir FranklySir is offline
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Join Date: Jun 2013
Posts: 177
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2confused,

I too had a 2 level with Dr. Clavel June 5th 2013. I a;leo have BCBS and own a small business in PA. My Ins co is having the first review this coming Friday.
Keep your fingers crossed for me. I did PM you the other day for any help you could provide.

I am hoping to win this round since now i need two level in lumber L34 L45. Not sure how long I can hang on at this point with not getting intervention. cannot even get a flight anyway before Christmas or more to the point afford it at 12500 per ticket.

Any help would be greatly appreciated per my PM.

Frank
__________________
Lumbar issues 18 yrs
herniations lumbar L3-5 multiple Epis etc etc
Annular tears L3-5 cauda equina
Cervical herniation symptoms 2011
C5-7 M6C by Dr Clavel on June 5 2013
L3-5 M6L by Dr. Clavel on 12.18.13
Living life instead of living the condition
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