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The Big File All issues not easily categorized in the above forums are here. Comments on general health, diet, "getting comfortable," and more are here.


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  #1  
Old 07-01-2005, 11:32 AM
Julaine Julaine is offline
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My pain management dr, scheduled me for some injections next week and the insurance denied coverage. When he scheduled these I had forgotten that last year they denied coverage as well so we went ahead and paid cash well i cant afford to and now what? first they deny adr surgery saying it isnt medically necessary and now they are saying the injections are not medically necessary. I am at my ropes end, what is the point in having insurance if they wont help me. I am ready to start filling my scrips for the patches and morphine they had me on, not take them just get them and make themn pay for all of it. I am in so much pain. Is this common? (insurance denial that is)

Julaine

--------------------
Back pain 10 years +
Chiropractic care 1993-1994
DX 2003 DDD at L4 5 S 1
January 04-Nov 04 Epi Injections
October 04- March 05 Morphine, vicodin, Duragesic,
Since March Drug free.
June:Now on Ultram
Blue cross denied my two level ADR.
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Back pain 16 years Chiropractic care 1993-1994DX 2003 DDD at L4 5 S 1January 04-Nov 04 Epi Injections October 04- March 05 Morphine, vicodin, Duragesic, June 05:Blue cross denied my two level ADR
august2005 woke up and had no feeling in legs was in
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  #2  
Old 07-01-2005, 11:46 AM
letteski letteski is offline
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Julaine

This is an atrocity how can they deny an injection for medication and give you a patch of morphine to get you addicted to medication. Are you doctors coding everything correctly? What is the diagnosis they are using? What are the codes? I had 2 injection earlier this year and will ask what the code and diagnosis was? I will be by the office today and will ask for you. This is absolutely appalling in my eye and you should fight this!
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Paulette
ProDisc L5-S1 W/Dr Delamarter Aug 23, 2005
L5-S1 DDD Diagnosis 12/04
T-12 Compression Fracture 10/04
C-7 Spines Process Fracture 5/99
http://prodisc2.blogspot.com/
You are my Rock God in you I can do anything
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  #3  
Old 07-01-2005, 02:05 PM
ans ans is offline
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I'm v. sorry to hear this. Dr. Kropf - Delamarter's partner - told me that BC in CA will be the last holdout on paying for ADR's. I don't know why.
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Severe, extensive DDD, considered inoperable by Dr. Regan, Lauressen, & some guy at UCLA. Severe foraminal stenosis (guess they can't operate!) and some spinal cord compression that Lauryssen would fix if gets outta hand.
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  #4  
Old 07-01-2005, 06:40 PM
Julaine Julaine is offline
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I am fed up with everything. I spoke with the surgery center and they called insurance and BC now says they are covering the procedure and I dont need pre authorization. The lady on the phone also told me that i dont need pre authorization for any procedure including surgery. which doesnt make sense to me. I have Blue Cross EPO, which is basically a PPO. Has anyone ever heard of this? Not needing authorization for a surgery.. if that is the case then heck sign me up!

Julaine
__________________
Back pain 16 years Chiropractic care 1993-1994DX 2003 DDD at L4 5 S 1January 04-Nov 04 Epi Injections October 04- March 05 Morphine, vicodin, Duragesic, June 05:Blue cross denied my two level ADR
august2005 woke up and had no feeling in legs was in
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  #5  
Old 07-01-2005, 08:40 PM
spotty14 spotty14 is offline
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I would suggest you file an appeal to their denial of the injections following the insurance companies procedures that are probably stated in your handbook. I wouldn't let them get away with not paying for treatment you have already paid cash for.If the appeal doesn't reverse their decision then you can file with the appropriate agency outside of the insurance company. My experience is that it sure works better to file in writing than just having the doctor's office call. It's ridiculous to pay premiums to insurance and then be denied. I hope you can change their decision.
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7/05 EMG/Nerve Conduction Tests
8/04 Disqualified from ADR clinical trial due to severe osteoporosis -- getting treatment
3/04 updated MRI
11/2000 IDET L 3/4, L4/5
1/2000 Discogram
numerous epidural injections
physical therapy
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  #6  
Old 07-02-2005, 12:04 AM
Kim Kim is offline
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Julianne
Not needing any preauthorizations sound fishy to me and believe me I would want something in writing stating they were payiing for any expensive procedure cause bottom line is you are responsible if the insurance company does not pay in most cases and most of us cant afford out of pocket expenses in the 10s of thousands of dollars. If you notice when you call your insurance carrier for any info you always get that lovely recording stating that anything they tell you can change so my policy is get it in writing or I dont depend on it
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Kim
Herniated disc L5/S1 2000 Discectomy 10/2003 Rhizotomy 8/2004 and 3/2005Discogram 11/04 grade 7 tear L5/S1
L4/L5 Grade 5 tear with herniation and stenosis
Evaluated by Dr Blumenthal at TBI
2/2005 ADR 2 level recommended
2 level lumbar fusion
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  #7  
Old 07-02-2005, 06:14 AM
Rein Rein is offline
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J - When you're dealing with issues this important it's always a good idea to get the complete name and position of the person providing the information. At the very least you then have either corroboration or someone to point a finger at when you receive conflicting information from some other source. Kim's absolutely on the mark; get it in writing!!!

As to the details of authorization, each BC issues a Member Handbook (which is *not* the contract) which spells out most details. Also important to obtain and read through thoroughly is the Benefit Description (which *is* your formal contract). You probably will have to ask your plan sponsor or employer (or whoever you get your insurance through) to provide a copy of the Benefit Description, which is the legal document that describes your coverage. The details in the Description are more extensive and need to be read and understood because they are the final, definitive answer as to what services are provided (or not).

Speculation here, but I wonder if the BC authorization for the procedure that Julaine mentioned might not be the change we've been expecting as of July 1, i.e., the new procedure approval codes. Prior to yesterday there were no approval codes for ADR and surgeons' offices were using other codes to enable these procedures. Of course it could just as likely be simply some dimwit in the doctor's office thinking about some other insurer's policy or something equally as mundane.
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03/09/26 - Ruptured L5-S1.

Years of pain, discectomy, research into anatomy, hardware, clinical trials, facilities, surgeons, techniques, insurance. Attempts at ProDisc, Activ-L trials. Now, low bone density. D'oh!!!

At 61 years, no longer qualifying for trials due to my age (chronological, not physical or mental).

2009 - Working on improving bone density or getting rich so I can go to Germany, where medicine and insurance have gone beyond the Stone Age.
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  #8  
Old 07-05-2005, 02:05 AM
paulam310 paulam310 is offline
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Julaine, I have Blue Cross PPO and my insurance covered all of my injections and surgeries. Hope this bit of info might be helpful.
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3 level prodisc C4-5,C5-6,C6-7
12-04
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  #9  
Old 07-05-2005, 04:47 AM
ans ans is offline
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My BCBS PPO in CA covered all of my injections. I could not get a straight answer from Utilization Review if they cover ADR.
__________________
Severe, extensive DDD, considered inoperable by Dr. Regan, Lauressen, & some guy at UCLA. Severe foraminal stenosis (guess they can't operate!) and some spinal cord compression that Lauryssen would fix if gets outta hand.
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  #10  
Old 07-05-2005, 06:58 AM
Rein Rein is offline
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Join Date: Apr 2005
Posts: 265
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J

Sorry I forgot to mention this in my previous post, but the two posts above this one confirm it, i.e., I think the denial of pain meds was a mistake, pure and simple. I'm pretty certain if you contact someone else at BC you'll find it was simply someone's error. This happens all the time.
__________________
03/09/26 - Ruptured L5-S1.

Years of pain, discectomy, research into anatomy, hardware, clinical trials, facilities, surgeons, techniques, insurance. Attempts at ProDisc, Activ-L trials. Now, low bone density. D'oh!!!

At 61 years, no longer qualifying for trials due to my age (chronological, not physical or mental).

2009 - Working on improving bone density or getting rich so I can go to Germany, where medicine and insurance have gone beyond the Stone Age.
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