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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 08-22-2014, 01:49 PM
Optimistic Optimistic is offline
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Henry....sorry to hear that you were denied, though this is only Round 1. It appears that not only did BCWW disagree with the "medical necessity", which your Doctor clearly wrote in his letter, but they tie the medical necessity to "the type of service rendered". This implies that you did need treatment but may not have needed ADR. This is just my take on the denial. For example, if you had obtained fusion surgery, BCWW may have approved this "type of service" as a medical necessity.

I wish you luck in the follow-up appeal. I am quite interested what other members like yourself include in follow-up appeals when their first application or appeal is all inclusive. Does anyone have thoughts on this?
__________________
1989 – herniated disc at L5-S1
1992 – L5-S1 broad bulging; right L5 nerve root compression; impingement on S1 root within spinal canal;
2006 – DDD L3-S1; disk bulge at L3-L4 and mild facet/ligmentous hypertrophy; L4-L5 large herniated disc; facet/ligmentous hypertrophy with stenosis; disc herniation & dessication at L5-S1;
2013/2014 – Dessication and significant disc height loss at L4-L5 & L5-S1; L3-L4 disc bulge with hypertrophy; mild spinal stenosis; Grade 1 anterolisthesis (3mm); L4-L5 - marginal spurring and moderate hypertrophy causing neuroforaminal narrowing; L5-S1 - moderate-severe neuroforaminal narrowing; lumbar lordosis is straightening.

New pains & functional limitations in late 2013 led to exploring ADR procedures. Consulted with 8 surgeons domestically and 9 in Europe.
May 2014 – Anterior and posterior incisions in a 5-hour surgery resulted in 2 M-6s and one facet joint prosthesis (dynamic stabilization system). On the road to full recovery.
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  #12  
Old 08-22-2014, 02:38 PM
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henry4956 henry4956 is offline
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Optimistic, I think you are right - now that I look at it again. Although in my actual phone conversation the person I spoke to was emphatic about the 'emergency' thing. He actually said to me that if the surgery was performed as the result of a car accident (for example) that I would have been covered. But in their statement as you point out the 'for type of service rendered' seems to be indicative of what you are saying.

Yet there are some like JasonHHH who had same procedure and he wins without appeal needed.
__________________
Bad fall on A$$, Feb 2001 ice hockey
Lami L4/L5 April 2001, L5/S1 Aug 2001
Severe dislocated coccyx (same fall)
Un-diagnosed til 09. (Cannot sit)
Low back pain mild until 2011 - pull started a generator from knees.
rhizotomy Nov 2011 - zilch
Facet joint inj. 18 mo. (no impact)
Can only stand/walk for approx. 30 min
21 hrs/day in bed
L3-5 Activ-Ls (April 2014) Dr Zeegers - walk every day, swim 3 x week. Pain free, no pain meds. Extremely pleased with my decision
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  #13  
Old 08-23-2014, 01:39 AM
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Kelly4ADR Kelly4ADR is offline
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Henry, I have yet to send you my info, but I will! Just a note, make sure you write down who you spoke with at the insurance co and even record the conversation if you can... If the employee tells you something, even if it is false (but in your favor) a lot of the time they will honor it...but you have to have proof.
__________________
2004 MRI -cervical bone spur causing pain
2011 MRI -5 bulging discs at C3-7: Recommended C5-6 and C6-7 for a two level fusion, I said no thanks.
2014 MRI -progressive compression C5-7.
MRI 6/5/14- Ruptured L4-5, bulge at L2-3 and L5-S1 Dr recommends discectomy of L4-5 but won't do surgery until cervical is stable
8/2014- 8 months/3 rounds of appeals, Aetna denies 2 level cervical ADR
2 level ADR w/ mobi-c C5-7 Jan 7, 2015
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  #14  
Old 08-31-2014, 02:10 AM
atxmom atxmom is offline
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Quote:
Originally Posted by henry4956 View Post
I've talked to JasonHHH (I think that's his name) on this site. He doesn't post much. I did everything exactly like he did, I'm still waiting.

Concerning the Pre-Auth. Very debatable as to whether you should or should not. Jason did not and got 100% and I tend to agree. My reasoning is this: The one thing I keep hearing overtones about is 'Emergency' vs 'Planned' I think Pre-Auth proves planning. Again, no one seems to have the blueprint on this. I think if they deem that the surgery was planned then it decreases your chance for reimbursement. Obviously we all have to plan this but... I really think it's a hit or miss proposition - no rhyme or reason
From what I'm gathering, it does come down to the emergency vs. planned. If it's emergency surgery then they will cover it. If you try to get pre auth, then it seems that they make you follow the regular guidelines of what types of surgery is normally covered. But I also agree that there doesn't seem to be any rhyme or reason. My policy just renewed and this year there is no penalty not getting pre approval. I'm just going to pay for it out of pocket & hope that there's enough to support that it was an emergency.
__________________
C3-4 5mm protrusion; cord contact
C4-5 3mm protrusion; cord contact
C5-6 3mm protrusion; Retrolisthesis 3mm; cord contact
C6-7 2mm protrusion; no cord contact

Waiting for 1st surgery
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  #15  
Old 08-31-2014, 02:26 AM
atxmom atxmom is offline
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Quote:
Originally Posted by Kelly4ADR View Post
Henry, I have yet to send you my info, but I will! Just a note, make sure you write down who you spoke with at the insurance co and even record the conversation if you can... If the employee tells you something, even if it is false (but in your favor) a lot of the time they will honor it...but you have to have proof.
This is correct, it might be hard to get them too do it but technically they are supposed to honor it. I don't know much about the health insurance but I have taken licensing exams for property & casualty insurance. It's called estoppel, if an insurance employee gives you information and you acted reasonably based on what you were told, they have to honor it. I've also studied it in my law classes, under the estoppel doctrine a company is liable for any damages that you suffer if you are misinformed.
__________________
C3-4 5mm protrusion; cord contact
C4-5 3mm protrusion; cord contact
C5-6 3mm protrusion; Retrolisthesis 3mm; cord contact
C6-7 2mm protrusion; no cord contact

Waiting for 1st surgery
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  #16  
Old 08-31-2014, 10:11 AM
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henry4956 henry4956 is offline
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I feel very good about the construction of my appeal. Kelly I know you are going to send me your docs, but in all honesty I have done a lot of background work on my own and I have consulted with an appeals specialist or 'advocate' if you will. I have (patting myself on the back) very good writing skills, and my main letter is coming along great.

I know when I say this, many will scoff at the notion that I am extremely confident that I will win my appeal, but I am. I should have it out within 2 weeks. I forgot how much time they are given to review, but I will keep everyone abreast when I win, I will then share my experience.

Hen
__________________
Bad fall on A$$, Feb 2001 ice hockey
Lami L4/L5 April 2001, L5/S1 Aug 2001
Severe dislocated coccyx (same fall)
Un-diagnosed til 09. (Cannot sit)
Low back pain mild until 2011 - pull started a generator from knees.
rhizotomy Nov 2011 - zilch
Facet joint inj. 18 mo. (no impact)
Can only stand/walk for approx. 30 min
21 hrs/day in bed
L3-5 Activ-Ls (April 2014) Dr Zeegers - walk every day, swim 3 x week. Pain free, no pain meds. Extremely pleased with my decision
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  #17  
Old 09-11-2014, 02:35 PM
Optimistic Optimistic is offline
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Join Date: Mar 2014
Posts: 81
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Hi Henry,
Any progress on your appeal letter? I am preparing for an appeal as well and "putting all the ducks in a row". I have some good references provided by Colorado Babe as well as my own research. It seems like the outcomes can vary by insurance carrier, pre versus post authorization, type of surgery (e.g. cervical or lumbar, one-level versus multi-level, etc.), level of support from local doctors, and many other factors. In spite of this, there is obviously some randomness in the outcomes.

It is very hard to predict whether the appeal will be successful. However, I still wish you luck Henry and pray you will be approved.
__________________
1989 – herniated disc at L5-S1
1992 – L5-S1 broad bulging; right L5 nerve root compression; impingement on S1 root within spinal canal;
2006 – DDD L3-S1; disk bulge at L3-L4 and mild facet/ligmentous hypertrophy; L4-L5 large herniated disc; facet/ligmentous hypertrophy with stenosis; disc herniation & dessication at L5-S1;
2013/2014 – Dessication and significant disc height loss at L4-L5 & L5-S1; L3-L4 disc bulge with hypertrophy; mild spinal stenosis; Grade 1 anterolisthesis (3mm); L4-L5 - marginal spurring and moderate hypertrophy causing neuroforaminal narrowing; L5-S1 - moderate-severe neuroforaminal narrowing; lumbar lordosis is straightening.

New pains & functional limitations in late 2013 led to exploring ADR procedures. Consulted with 8 surgeons domestically and 9 in Europe.
May 2014 – Anterior and posterior incisions in a 5-hour surgery resulted in 2 M-6s and one facet joint prosthesis (dynamic stabilization system). On the road to full recovery.
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  #18  
Old 09-11-2014, 04:02 PM
FranklySir FranklySir is offline
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Join Date: Jun 2013
Posts: 177
Cool They are nuts

Opti and Henry,

Not to be a downer but they will try anything they can to not pay.

Opti you are correct regarding emergency. It still doesn't matter. Just went to my 2 level in person and they fought me all the way. The Doc on the panel couldnt believe his eyes when I walked in. then was in total disbelief when they found out I had the neck done as well 6 Months prior. He actually nodded his head and smiled in approval.

I have and had all documentation and 3 letters from the surgeon. With the last one stating exactly that Emergency along with 8 exhibits all bound nicely for each member. Their jaws dropped when I pulled all the stuff out. Cauda Equina Syndrome is a clear emergency under any curcumstance. Now I am not sure as to the outcome yet since they have 5 days to finalize. What I can say is you need to use the handbook against them. They will find any small thing to wriggle out of paying. I have read this book cover to cover and flagged everything. I found some interesting things of which would be a no brainer to beat them with their own book. Wont post it here to broadcast but I know 100% if they deny me again I will win with the Insurance commission and plan on taking them to task.

For me its sport. All upside since I could really care less about the money. Yes I would like to get it back but Im having fun with this!!!

More to come. I hope you guys make out well too.

F
__________________
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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  #19  
Old 09-11-2014, 04:19 PM
drewrad drewrad is offline
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Join Date: Jan 2014
Posts: 629
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Heh. You're a sick man Frank. Making sport. I like it!

Yeah, at Kaiser when I showed my doc the images he, too, had that kind of kid in a candy store fascination about it.

Poor US docs, they're handcuffed and can't play with the big kids on the upper playground.
__________________
Weightlifter since 12 years old, now mid-40's and figuring out this wasn't such a good idea.

Chronic back pain started in 2010 while shrugging weights that a 40 yr. old shouldn't even try.

MRI in 2012 showing L4/L5, L5/S1 herniations and L2/L3 bulge.

L5/S1 taking on new shape, chronic sciatica, etc.

DEXA bone scan performed 5/7/14 showing mild osteopenia.

Surgery performed July 9th, 2014, Dr Clavel, hybrid three level lumbar.
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  #20  
Old 09-11-2014, 04:37 PM
henry4956's Avatar
henry4956 henry4956 is offline
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Join Date: Oct 2013
Posts: 250
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very good stuff. I have taken a lot of good advice from Frank and others. I am exceedingly confident that I will beat the odds. I have been pouring myself into this appeal. Good luck to you Optimistic as well
__________________
Bad fall on A$$, Feb 2001 ice hockey
Lami L4/L5 April 2001, L5/S1 Aug 2001
Severe dislocated coccyx (same fall)
Un-diagnosed til 09. (Cannot sit)
Low back pain mild until 2011 - pull started a generator from knees.
rhizotomy Nov 2011 - zilch
Facet joint inj. 18 mo. (no impact)
Can only stand/walk for approx. 30 min
21 hrs/day in bed
L3-5 Activ-Ls (April 2014) Dr Zeegers - walk every day, swim 3 x week. Pain free, no pain meds. Extremely pleased with my decision
Reply With Quote
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