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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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  #21  
Old 10-30-2007, 05:44 PM
Liz Liz is offline
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3 appeals denied by United Healthcare last year and initially this year for 2-level Prodisc not b/c multilevel but b/c UHC claims experimental/unproven treatment for DDD. I paid out of pocket with Dr. Delamarter; UHC denied coverage on the date of my surgery. B/c self-funded plan through my employer I was not able to appeal to the CA Insurance Commission or the CA Dept. of Managed Healthcare. I am still in appeals process for reimbursement but do not expect that will happen. Not workers' comp.
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scoliosis; 1998 snowboarding injury->DDD L3-S1 w/annular tears/protrusions; 2007 episodes of rt foot drop
2007 Prodisc ADR L4-S1
L4-5 Prodisc tilted/facet issues; old L5 nerve damage
2009 L4-5 Prodisc ADR removed and revised to XLIF w/posterior instrumentation
massive hemorrhage from tear of inferior vena cava at right iliac vein due to adhesion from Prodisc op
2010 not fused; as a result of complications permanent nerve damage to lumbar plexus causing severe rt leg, hip, groin pain
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  #22  
Old 10-30-2007, 08:14 PM
CindyLou's Avatar
CindyLou CindyLou is offline
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Join Date: Mar 2007
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I'm in Minneapolis, with HealthPartners, self-funded plan thru spouse's employer. Denied 3 appeals for 3 level lumbar ADR. Paid out of pocket to go to Germany for Dr. B. Not worker's comp.
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CindyLou
bicycle accident 6/19/01
2 compression fractures, T12, L1;
vertibroplasty @ above levels, 9/15/01
4/06 hip labral tear repair
4/07 Lumbar ProDisc replacement by Dr. B., 3 levels; L3-6
7/2/08 ALIF of L6-S1
7/30/08 Removed bone cement.
8/7/08 Diagnosed with pulmonary embolism, double pneumonia, collapsed left lung, pleurisy, pleural effusion.
3/10/09 right SI Joint Fusion; seeing light at end of tunnel, for first time in 8 years!!
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  #23  
Old 10-31-2007, 01:58 PM
FUZZDOG FUZZDOG is offline
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Join Date: Sep 2007
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I am in Illinois.
cigna ppo is my primary carrier.
2 appeals denied.
bc/bs il is secondary carrier.
2 appeals denied.
ADR Charite device at l3-l4, "hybrid" application combined with 2 level fusion below at l4-l5-S1.

Was denied as considered experimental technology. Also because it is outside the FDA approval criteria as being used at l3.
FDA approval for charite is for single level from l4 to s1 and thus my surgery did not meet specifics.
I am not a work comp case.
4 level fusion still pending approval they are also fighting on that one!


ck
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ACDF C5-C7 2002 with hardware
PLIF L2-S1 11/28/07
NSPINE DEVICE USED AT L2/3 ..fused with hardware to s1...
severe ddd for 10+ years tried every conservative therapy avail denied hybrid adr l2/l3 combined w fusion 3 appeals
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  #24  
Old 11-01-2007, 11:37 AM
chasswen chasswen is offline
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denied and used all appeals with blue crap of penna.
IBX blue crap. Self paid to go have dr. b preform a single level at l5-l6.
after returning home submitted again to blue crap as out of network and was told i was to receive payment then they turned around again and denied the entire thing.
so i have given up as far as suing them as you cant get any thing back accept the cost of the surgery. no lawyer fees no travel fee etc... GRRRR
ok enough of that now just writing about it again has in raged me once again.
chuck
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ddd 1990
2003 mri,xrays,shots,emg
2004 discogram ouch pos l4 l5
facet block neg
lost all appeals BCBS 5 months of that
3 surgeons later
surgery with dr. bertagnoli aug 2nd 2006 in Bogen Germany Successfully ProDisc-L L-4 L-5
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  #25  
Old 11-09-2007, 11:24 AM
steve h steve h is offline
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Join Date: Nov 2007
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i am a 43 yr old male. denied L5/S1 disc replacement by unicare insurance. no worker's comp -- only personal health ins policy. i am optimistic to be chosen for active-l disc study beginning in dec.
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  #26  
Old 11-11-2007, 09:15 AM
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Denied, Denied, Denied...UHC, PPO two level L4-S1 ADR and/or hybrid. Final decision came from the company's Director of Human Resource. Not a WC.

I agree with Chasswen, just typing this puts me in a BAD MOOD.
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  #27  
Old 11-11-2007, 12:16 PM
KL Aguilar KL Aguilar is offline
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Join Date: Dec 2006
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I live in Southern California. I was first injured in a student fight, at the high school where I was a teacher. I suffered a second injury lifting a heavy box over another one, also at work. No surgeon on the list Workers' Comp gave me does cervical ADR, so in effect, I have been denied. Dr. Regan (not on my list, I paid to see him and another surgeon out of pocket) recommended a two-level ADR.
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--------------------------------------------
First injured C4-7 in 9-95.
Had CED (MISS) at those levels 1-00 and regained my life.
New injury + re-injury C3-7 in 8-06, initially causing "claw hand."
Latest MRI shows: 4.5mm disc protrusion,
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  #28  
Old 11-17-2007, 09:12 AM
sessler sessler is offline
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Join Date: Sep 2005
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Hi all,

Been denied,denied, denied by Blue Crap of Nebraska for a single level Charite.

Had to go fusion route on L4-L5. I am just about three weeks out and I remember that I felt better when I had ADR surgery.

Sue S
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Sue
L5/S1 Microdestomy 10/1999 Failed
L5/S1: Keniflex Disc 7/2005
L4/L5: Fused 10/2007
Been denied several times by BCBS of Nebraska
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  #29  
Old 11-17-2007, 11:25 PM
LBP LBP is offline
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Join Date: Aug 2005
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Sue,

I find your post a little alarming. Hope you can expand on your "signature" a bit.

What jumps out at me is that you're having a fusion at an adjacent disc level just 2 YEARS post ADR????

Since you had Kineflex..I am thinking it's likely you were a participant in a Kineflex ADR clinical trial.

Did you specifically and medically determine that your L4/5 was healthy before entering the clincal trial on your L5/S1 or did they think your L5/S1 was worse and somehow you still got into the trial when you where really a 2 level candidate before your ADR trial.

Do you understand what I'm getting at? Because the point of ADR is to preserve motion so you don't need another surgery at an adjacent level, especially so soon.

Just raises a red flag! Hope you can shed some light onto your specific circumstances.
__________________
Injured 9/01
Annular tears L4/5 & L5/S1
denied adr by insurance for 2 level charite as well as hybrid fusion at L5/S1 with Charite at L4/5.

New ins paid for 2 level lumbar prodisc surgery on 4/7/08 (at age 39) with Dr. Westerlund, at Core Orthop
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  #30  
Old 11-19-2007, 08:48 AM
sessler sessler is offline
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Join Date: Sep 2005
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LBP,
I am on the Keniflex/Charite study. At the time I really did need a two level. My surgeon and did speak about this and the study was for only one. He put himself out on limb and decieded to replace the worset disc which was L5-S1. The disc was totally discenagraded. We were hoping that L4-L5 would be ok.
About six months after the ADR, L4-L5 started acting up. I have not had any problems with the Keniflex disc. My opinion that this ADR is fantastic and if I could I would love to have another one.

Does this answer your question LBP. I will change my signture.

Sue S
__________________
Sue
L5/S1 Microdestomy 10/1999 Failed
L5/S1: Keniflex Disc 7/2005
L4/L5: Fused 10/2007
Been denied several times by BCBS of Nebraska
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