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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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Old 08-07-2014, 10:03 AM
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Default Tricare - Women Veteran's

I am another Tricare recipient and have been denied for a multi-level cervical artificial disc and a lumbar Artificial disc. Tricare claims they will only cover one cervical ADR and not multi-levels. They also claim that the lumbar ADR is on the no pay list. I have appealed and they continued to deny. I sent in my packet yesterday for outside agency to review and consider but now I am regretting it as I just got on this forum last night. I am pretty sure it will be denied again as I only submitted evidence based practices showing that multi-level and lumbar ADR are not experimental and they have a higher success rate that fusion.

Today, I am submitting a package to the VA asking them to pay for the three ADR's since they are all service-related and I am rated 80 percent disabled from the VA. I am hoping they will approve the expense but I doubt it. I will keep you posted as I try to be positive.
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Old 08-07-2014, 12:08 PM
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Babe,

This link may be helpful. It reports that a US insurance carrier was court ordered to pay for a multilevel ADR because that carrier had failed to prove that the procedure was experimental.

Good luck, Jeff
__________________
C4/5 - ACDF in 2000
C5/6 - ACDF in 2002
C3/4 & C6/7 - M6 ADR, Nov 2009, Barcelona
Conceded defeat to a manifestly disingenuous BCBS-TX in my quest for reimbursement, Jan 2011
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Old 08-08-2014, 10:56 AM
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Thank you so much JSS. I will send an addendum letter to the second level and ask them to add this to my appeal. I will keep everyone posted.
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1998- Injured neck and back in USAF
2011 - Started experiencing Severe Symptoms, Migranes, numbness, spasms in legs and feet and sciatica.
Feb 2014 - Received upper Lumbar Injection - Severe Allergy to injection
Mar 2014 - MRI of Cervical and Lumbar, protruding disc in C3-7, Herniated Disc in L5/S1, placed on STD and FMLA )
July 2014 - Stem Cell Procedure performed
Oct 20, 2014 - ADR (MOBI-C) at C5-7 and Anterior Fusion at L5/S1 by Dr. Pettine and Dr. Techy
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Old 08-16-2014, 10:40 AM
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colorado babe colorado babe is offline
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Thank you JSS I truly believe the link you sent me helped me tremendously in winning my third appeal. Thank you, Thank you, thank you!
__________________
1998- Injured neck and back in USAF
2011 - Started experiencing Severe Symptoms, Migranes, numbness, spasms in legs and feet and sciatica.
Feb 2014 - Received upper Lumbar Injection - Severe Allergy to injection
Mar 2014 - MRI of Cervical and Lumbar, protruding disc in C3-7, Herniated Disc in L5/S1, placed on STD and FMLA )
July 2014 - Stem Cell Procedure performed
Oct 20, 2014 - ADR (MOBI-C) at C5-7 and Anterior Fusion at L5/S1 by Dr. Pettine and Dr. Techy
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