Fusion Insurance Coverage

[Judy]

I don't know whether anyone will be able to help on this and I apologize in advance this is long:

Fusion and ADR surgery done at the same time. Processed claim for the FUSION only (done overseas). This was back on 12/29/04. They went back and forth until April and decided they weren't going to pay because it was ADR and is experiemental. At this time I explained I did not place a claim for the ADR I didn't even send them the invoice for this. Well they then said they would look at this again and I alos gave a medically necessary letter for the surgery.
They have taped conversations with me a customer rep prior to surgery where they did not say they would not pay for surgery done out of the country and this is another reason they said they would review this again.
Almost ten months later I finally heard from this week and again due to experiemental reason they will not pay. They said if I had the surgery done on two different days they would pay. They claimed they had their lawyer look at everything etc. and they were not going to give me anything in writing to this effect they said I still have the April decision and I can just use this. At this point I was very upset and explained I wanted this in writing so I can start the appeal process and if she really knew their policies she would understand that you only have so much time to appeal and that 6 months would then too late. She also explained the cost of the fusion in the US would be approximately $7500, I said I don't believe you can have any surgery done in the US in a hospital for $7500 and she said they if I can get her the code of a fusion maybe she would then look it up and see. See I belive Cigna screwed up when they did not tell me that overseas was not covered and why would any claim take 10 months to be processed if there isn't something there they don't want me to know. I also asked for all the typed conversations of all my calls since last July. They would look into their company policy and see if it allows them to do this.
Now for the appeal, for the fusion/adr where do I start. I am sure that many people on this board have alot of information or can at least point in the right direction. I think my biggest part of this is some kind of backup of the medically necessary for me to have a combination surgery versus going through two surgies, and where might I get this type of information. Where can I get information on the cost of a fusion?
I know I have a lot of questions and if anyone can help me I would greatly appreciate any information you have. Again I want to go after payment for the fusion only at this point.

[JoJo]

That's ridiculous! Just another clerk, I guess, answering MEDICAL questions! I'm no expert, but I'm thinking that maybe the doc put the wrong codes in? I've been thinking a lot about this, wondering what the insurance companies do. I mean, you can't separate the two surgeries (fusion and adr) so is that how some patients get by with only paying for the adr, and having the ins company pay for the rest?

Well, I guess I'm not much help. But I have a lot of sympathy!

[go*big*red]

Maybe you should call your Connecticut Insurance Commissioner. Be sure you have everything in narrative form that you can either fax or e-mail them.

Their job is to go to bat for the consumer - you - they are your advocate and you certainly need one in this instance.

Just out of curiousity, why did they do a fusion and ADR? Why not a multiple level ADR instead? I'm just curious for my own personal reasons.

[Dale S]

Judy,
I'd be very wary of the legalities of your insurance company refusing to put something in writing. You should document every conversation as to date, time, the reps name and of course, the content. You should also insist on speaking to a supervisor to confirm this refusal so as to avoid any possible misunderstanding or their denial that the conversation ever took place.

As far as costs, J&J sells the Charite disc for $11,500, Dr. Regan in Los Angeles charges $7,500 for the first implantation and half that for additional levels. I do not know the specific cost for a fusion. The assistant surgeon is about $3,000 and the anesthesiologist - about $1,500. Hospital charges which include OR time, daily room rates and meds are additional. For a 3 level plus 1 fusion, Cedars wanted $78,000 up front, for a 3 day stay, and the Doctor's Hospital wanted $90,000. From that, I would think you'd simply subtract one level disc ($11,500) to get your cost. In Germany, my costs which include airfare, hotels and meals will be less than half.

BC told me that they do not pay for out of the country medical care unless an emergency. They also denied my U.S. adr, and would not separate the fusion and adr unless done in 2 surgeries. I am going to Germany in December and will submit all my bills to BC for reimbursement... and will litigate if necessary. I cannot tell you what the outcome will be.

If you get no satisfaction from your state ins. commissioner, you will probably need legal representation... and they will need your documentation of phone calls.

I wish you a lot of luck!

Now that your 1 year anniversary is approaching, how are you doing? Is your pain gone... has your life improved?

Dale

[sahuaro]

Unfortunately, I cannot provide info relevant to your questions re your surgery. But I do know that one of my patients (I am a psychologist) called her insurance to verify coverage, kept detailed notes of the conversations, including dates, times and names; when coverage was subsequently denied, she was able to use this information--and her knowledge that these conversations are recorded--to get the insurance company to admit that they had misled her and to pay for expenses incurred until the time of their appeal decision. She gets her insurance through her employment with a major corporation and was able to get the Human Resources department involved in her appeal. So--there are two aspects to your appeal, it would seem: both the insurance company's misleading you and the medical necessity issues. That Cigna will not put anything in writing at this time seems very suspect.

[Judy]

I agree with you all, unfortunately I only remembering talking to them not the actual conversation. As a matter of fact they also told me over the phone they were going to pay the claim (without the cost of the discs) before they realized it was all done in one surgery then came the denial. I want to figure out how to call the hospitals to get the cost (approximately cost) of a one level fusion, then I can ask my doctors office here to give my an estimate on what his bill would be. That be done, I think I will surf the net and see if I can get any articles about the the risks of any surgery and maybe go about that way, they it would not be medically best for me to have had this done as two surgeries.
Any other thoughts. I will definetly call the state commisions office after I get everything together at the same time as doing my appeal.
If any one has any information or documents (example estimates of fusion surgeries) that you think will happy me I greatly appreciate it. I would not use any ones names though just the hospital date of estimate and the estimate.
Thanks again

Judy

[NCFUSED]

Judy,

Just an FYI my total PLIF Fusion costs were billed by the hospital @ 42,000. UHC discounted that price to 8600.00.

John