Did your insurance pay? Let's help one another

[Rein]

It's that time of year where my wife and I can change insurance carriers at her place of work. Since it's obvious Blue Cross is totally random and there's a good chance they may not cover my ADR until well into next year (unless I can sort out an arrangement similar to Rich's), anyone had any contact with Harvard Pilgrim of Massachusetts?

[Nichole]

LaJeana You are so welcome. There have been many angels before me who have helped me trudge thru my own hell and I am proud to help in any way possible. Keep me posted definately about your progress and if there is anything else I can do to help. Research, phone calls anything.

Nikki

[Jim M2]

Hi,
Rein has asked me to post more about my insurance experience with ADR.

Pre-surgery Regence Blue Shield in Washington told me they pay only according to accepted diagnostic and procedure codes. They would not pay for ADR, which in 2003 was not approved. I did not bother to fight them. I did not have the energy. I had no documentation to offer. I had some money so I paid for the surgery in Germany.

Several weeks after surgery I submitted a written appeal (SEE THE LETTER BELOW THE ASTERICKS) requesting to be reimbursed for medical costs. About 50 pages of doctors office notes, radiology reports and all of the bills and descriptions of services from Germany in German were attached to the appeal. Several weeks later I received a check for 89% of the total.

It makes me angry and frustrated to know you are going through this while you are so sick.

Best wishes,
Jim

*****************************
October 24, 2003

Regence Blue Shield and The Company (my employer)
<note: Regence's address for appeals was here>

Dear Appeals Specialist,

PUPPOSE
I am appealing to Regence Blue Shield and the Company to reimburse me for medical costs of artificial disc replacement (ADR) that were incurred in August and September of 2003 in Munich, Germany. Please respond to this request in writing to the undersigned.


INTRODUCTION
In May 2002 I developed chronic, severely debilitating low back pain. In search of relief I visited numerous physicians including a pain management doctor, orthopedic surgeons and neurosurgeons. MRI, X-rays and CAT-Myelo diagnostics all confirmed a collapsed lumbar disc at L5S1. Medications, physical therapy, exercise and severe restriction of activities brought only limited reduction in pain levels. After months of research on the topics of spinal disorders, fusion and ADR I opted for ADR. In August 2003 I traveled to Munich, Germany and had ADR by Dr. Willem Zeegers at the Alpha Clinic.

LETTER OF MEDICAL NECESSITY
I am submitting this letter together with the writings of five surgeons as a Letter of Medical Necessity.

The first three writings are office notes from the U.S. surgeons who personally examined me in 2002 and 2003 prior to surgery. Their names are Dr. Villanueva, Dr. Schlitt and Dr. Krengel. Their office notes are attached. All three surgeons speak of spinal fusion as the primary option to be considered in my case for pain reduction and increased functionality if conservative treatment did not improve my condition.

The forth writing is from Dr. ML Whitworth. His writing is a matter of public record. It can be found online at the Massachusetts General Hospital Neurology discussion forum. A copy is attached. Dr. Whitworth feels "fusion is an archaic barbaric anachronism which is only necessary if there is significant spondylolisthesis or foraminal stenosis..." In the attached writing he goes on to justify this statement, to advocate ADR under protocol and to explain that many surgeons continue to perform fusions for monetary reasons.

The fifth writing is a diagnostic report on my condition from Dr. Zeegers of the Alpha Clinic in Munich, Germany. Dr. Zeegers is the world's leading ADR surgeon. He has performed over 1000 implant surgeries since the 1980s. After examining my MRI, CAT-Myelo, x-rays, radiology reports and patient questionnaire he concluded that I was a good candidate for ADR, pending a personal examination in Munich.

Beyond these writings I read extensively on the topics of spinal disorders, spinal fusion and ADR to ascertain my understanding of the risks and potential benefits of these two medical procedures. My conclusion matched that of Dr. Whitworth and Dr. Zeegers. It was my conclusion that ADR was statistically superior to fusion for pain reduction, improved functionality and better prospects for long term health.

ADDITIONAL CONSIDERATIONS
1) ADR at Alpha Clinic costs $20K. It is my understanding that ADR under FDA trials in the U.S. costs $60K. It is my understanding that costs for spinal fusion in the U.S. range from $50K to $80K.

2) Dr. Zeegers is the world's leader in ADR. He has performed over 1000 implants of the SB Charite artificial disc since the 1980s.

3) Surgery was needed in the near term to relieve pain, prevent degeneration of facet joints and to eliminate potential for nerve damage.

4) It stands to reason that European surgeons performing ADR would have a higher success rate when compared to their lesser experienced U.S. counterparts.

MEDICAL ACTIVITIES AT ALPHA KLINIK
On 18-Aug-2003 I departed for Munich, Germany. On 21-Aug-2003 I was personally examined by dr. Zeegers at the Alpha Clinic. X-rays were made of the lumbar spine and discography was performed on levels L2S1. A complete physical examination which included chest x-ray, EKG, breathing and blood test, was performed. I was fitted with a custom made lumbar corset. On 22-Aug-2003 a Charite artificial disc was implanted at the L5S1 level of my spine. I spent four nights in the Alpha Clinic hospital before being released on 26-Aug-2003. Just prior to release from the clinic more x-rays were taken to verify placement of the implant. An ultrasound test was conducted to verify the absence of thrombosis. In the two weeks after surgery I received two more personal examinations by Dr. Zeegers and five sessions of physical therapy at the Alpha Clinic.


SUMMARY OF MEDICAL CHARGES AND PAYMENTS
Receipts, exchange rates, accounting and descriptions of services are attached. Payments were made by wire transfer and VISA card. Approximately $6K of travel expenses and lodging have been borne by myself.

CHARGES
ITEM EURO
Brace Shop 1,000.00
Anesthesiology 1,540.66
Medical Exam 300.00
Alpha Clinic 10,389.90
Surgeon 4,371.52
Ultrasound 88.27
Physical Therapy* 450.70
-------------------------
Total 18,141.05

PAYMENTS
ITEM EURO US DOLLAR
Wire Transfer 15,256.97 17,250.00
VISA 1,000.00 1,101.76
VISA 1,345.11 1,481.98
VISA 88.27 97.25
VISA* 350.56 393.34
VISA* 90.14 101.14
-------------------------------------
Totals 18,131.05 20,425.47

*Discrepancy between charges and payments for physical therapy appears to be a clerical error where Alpha Klinik billed my VISA 350.56 Euro instead of 360.56 Euro.

CONCLUSION
Regence BS and the Company are requested to pay $20,425.47 to the employee to meet their obligations as his health care provider. Please respond to this request in writing to the undersigned.

Sincerely,

Jim M2

[Rein]

Right on, Jim!!! Thank you very much for sharing with us that extensive and very detailed information. This is exactly the kind of stuff many people need to get what they deserve.

[Jim M2]

Rein,

I hate to disappoint but I've PM'ed this appeal letter to some others. They were not successful in their appeals.

In my case the Company was self insured. Blue Shield was contracted by the company only to administer the plan. Appeals were probably decided by the company since it was their money.

That said, the appeals letter and it's attachments were complete enough to satisfy the decision makers.

Jim

[Kat]

I am pretty new here and have UHC insurance. They denied my ADR and I am currently on my 1st appeal. Awesome letter Jim...I may use that on my next appeal. There are some VERY interesting things going on here in St Louis regarding UHC though. 3 major hospitals in the area are no longer going to accept UHC insurance in a protest. It is my understanding, that UHC is accused of "steering" patients towards certain doctors. Has anyone in other parts of the country heard of this???

Since they denied FDA approved ADR, makes me wonder if they aren't "steering" patients towards certain medical procedures....Hmmmmm, I wonder.

Kat

[amanda]

Hi Kat,
UHC denied my husband's L5-S1 ADR thru Texas Back. I appealed it (with 120 pages of documentation). They just denied ADR again. I spoke with a supervisor yesterday who requested that I resubmit the appeal to her directly. She received it today. We'll see what happens. If anything good happens, I'll let you know. Jim's letter is awesome. I wish we could get "60 Minutes" or similar involved to expose the extreme pain, suffering & grief of patients denied by United Health Care & others...something to garner public sympathey awareness on the subject.

[David]

UHC here as well, although my doctor is waiting for the results of my 2nd discogram before oficially submitting his L4-L5 charite pre-certification request.

He seems to think that we won't have any issues, although I am extremely skeptical. Should find out in 3 or so weeks (discogram is 17-JUN).

David

[Juli]

I also have UHC. I will be submitting my pre-certification after my 2nd opinion with Dr. Bitan on Friday. I was recommended for a two level at L3-L4 and L4-L5 by Dr Zeegers last week. I am going to submit both next week(assuming they are in agreement) and cross my fingers (toes, etc..). I will post how that goes and am interested to see how you guys that
also have UHC fare. So far, no one I know with UHC has been approved. At this point, I am assuming I will be paying for it so expect to be having the surgery in Munich in the fall.

[Rein]

Here's a member from Tennessee who managed to get BCBS to cover his ADR at TBI:

posted June 06, 2005 09:57 PM ��� �� �� �� � � �� ��
I am leaving tommorow morning for Plano, Tx. to have one level ADR L5S1 to be performed by Dr. Blumenthal at the Texas Back Institute. My BCBS is covering the procedure and my hospital stay. This is one surgery that i am actually looking forward to having. I want to thank some of the people who post on ADR forum, especially my friend who also lives in TN. for there support and advice. My friend in Tn. was very supportive and helpful.
Sincerely, JF110

Here's a link to his post:

http://www.adrsupport.org/private-cgi-bin/ultimatebb.cg...;t=000541;p=1#000000