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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 11-09-2008, 06:52 PM
GaryC GaryC is offline
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Join Date: May 2008
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Angry Thanks for NOTHING, TRICARE!

As I write this, it is 7 months + 1 day that TRICARE first denied ADR for my herniated L5-S1 disc, claiming it to be unproven technology.

I appealed the first denial and - guess what - I was denied again.

I appealed the second denial and requested a policy review. It took roughly 5 months for them to perform this review and - big surprise - they denied it again.

Not only did they deny coverage again - they said I could not appeal the denial because it was based on a factual examination of the case and the medical literature. In addition to taking away the only option that is acceptable to me (ADR) they refused to tell me of any other options.

They (TRICARE) claim they are acting in the benefit of service members and retirees to provide them with quality care, yet deny the one option that will give me optimum quality of life. As of now, I have no quality of life. I go to bed every night wondering if I'll be able to walk in the morning, but they don't care.

I provided them with more than enough evidence to support my case, including cost analyses, yet they were unconvinced.

Now what do I do? I can't hobble around for the rest of my life. This is insane. I put my life on the line for this country for nearly 20 years and this is the thanks I get - sorry, we won't help you, even though this was probably caused by your military service. Your only options are spinal fusion and physical therapy. PT hasn't worked, and fusion is unacceptable.
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Gary Christopher
Retired Navy (1995) Submarine Force
2 bicycle accidents 1 car accident
LBP 2003 - MRI herniated L5-S1
Microdiscectomy/Laminotomy 2003
2008 pain returned
PT didn't help
L5-S1 totally dessicated
Vicodin PRN

Last edited by GaryC; 11-10-2008 at 11:31 AM. Reason: Insert Signature
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  #2  
Old 11-09-2008, 07:17 PM
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Harrison Harrison is offline
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Default This is Nuts

Gary, sorry about this terrible news which many of us can relate to in so many ways! I'd like to comment about your situation, but I don't know much about the specifics of your appeal. When you are ready, please insert a signature which briefly describes your spine condition. Sorry to ask now...not very good timing.

As you may know, active duty personnel have gotten ADR on many occasions. There must be a way to leverage this as a precedent.

I'll check back in a few days. We can also talk about next steps by phone mid week.
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Fell on my ***winter 2003, Canceled fusion April 6 2004
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  #3  
Old 11-09-2008, 11:12 PM
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KBear KBear is offline
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Gary,
First, I would like to Thank You for your service to Our Great Nation. You are a hero and should be treated as such. Unfortunately, our goverment does not treat any of our veterans the way they should be treated. I am on my first insurance denial, working on getting an appeal together. If that falls through, I am going to be in a clinical trial. Would that be an option for you? There are many clinical trials across the US, several of which the control and experimental are ADR (so either way, you get ADR). You can look up trials for your problem on http://clinicaltrials.gov/ and find trials in your area. I would at least check and see if there is something in your area, or if not, if it is feasible, travel to another state to have it done.
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  #4  
Old 11-10-2008, 03:16 AM
kimmers kimmers is offline
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GaryC,

I was under the impression that Tricare covers ADR. My sister and brother-in-law have TriCare and my sister recently got a letter from Tricare saying they were now covering ADR. She read the letter to me over the phone.

Maybe it is not for lumbar ADR?

I would suggest that you keep fighting for ADR. If you can be in a trial, that might be good. I would just keep fighting.
I got ADR when Blue Cross wanted me to get fusion.
I determined that no insurance company was going to tell me to have a surgery that my surgeon did not recommend. That is not right in any case.
I have gone to great lengths to go after the insurance company. I have put in so many hours fighting an insurance company that could care less about me. I have been in the newspaper, on the radio, the internet, and hopefully soon on NPR.

I stopped short of driving to Woodland Hills.CA and laying down on the steps of Blue Cross/Anthem/Wellpoint until the cops removed me.

I have to admit that I thought of it often. I get sick to my stomach when i think of Blue Cross because they tried to ruin my life and they are doing the same to a lot of people. People shouldn't have to decide between their retirement and their life.

My insurance (so-called) only allows for 24 physical therapy visits so I have had 36 and therefore I am out of PT. My PT is going to ask for more visits with a letter of medical necessity from my doctor, but I don't hold out much hope. I have gone through this before when i had DDD and a herniated disc and those ******** denied me PT because I had used it for a different problem. Blue Cross actually said I had a nonoperative muscle strain. Our so-called state Dept of Managed Care sided with them.

It is awful that we cannot get FDA approved treatment in the United States. Keep fighting.

Kimmers
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hurt back lifting, herniated disc at L4/L5. DDD
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  #5  
Old 12-10-2013, 07:51 PM
CCFour CCFour is offline
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tricare will cover C-ADR, but not TDR/ADR. they gave me the resone that it is un-poven.
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  #6  
Old 03-07-2014, 09:00 PM
Jerry5 Jerry5 is offline
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Join Date: May 2013
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Default VA

The VA will not cover anything other than Fusion. Mark the date of this email.
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Jerry, Somewhere Ohio

L2-3 herniation, two days before Thanksgiving, 2012, Discectomy/Laminectomy, 3/13 Numbness in the right leg, lateral femoral, gone, July 10, 2014 L45 M6 ADR, July 15 PLIF L5-S1, Not able to access L51 Anterior.
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  #7  
Old 08-06-2014, 09:39 PM
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colorado babe colorado babe is offline
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Tricare is now approving single level cervical ADR. However, they denied me because I need two-level cervical and a lumbar ADR. I appealed and they denied. Sent my paperwork on to the second level reconsideration company today and cc'd my congressman who is trying to help.
Tomorrow I will be dropping off a packet to the VA to see if they will pay for the surgery since it is all service related and I'm rated 80 percent disabled through them.
It's a disgrace that us veterans have to fight for our medical care. I served my country for 22 1/2 years and feel like I've been spot in the face by our country.
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