US Insurance

NCFUSED · #1 01-10-2005, 07:57 AM

First of All, this site is great!!! I have found a lot of answers to my questions already....

I am a candidate for the Charite ADR Surgery, but have run into a roadblock with my Health Insurance (UHC) paying for it.... Has anyone had any luck winning an appeal???

My back is getting so bad I am about to give up and just opt for fusion??

Thank You in Advance,
John
Greensboro, NC

Harrison · #2 01-10-2005, 10:17 AM

Hi John, welcome to the site. Please tell us a little more about your spinal condition if you can.

The insurance "game" is a frustrating one for many here. I went through a long process of appeals with BCBS and successfully got reimbursed for my ADR -- definitely one of the few and lucky, as I had it before the Charite' approval in October.

There's more info here in these threads. If you want more details, feel free to email or PM me.

#3 01-10-2005, 07:05 PM

A good way to bully insurance co. to pay is to ask them directly who personally is denying your FDA approved surgery, and don't stop until you get some names. Ask them if you are approved for fusion surgery? Then inform them that if you are forced into fusion because of their refusal to pay for this approved procedure, you would be left with no recourse to hold them corporately and personally liable for any pain and suffering when it leads to future disc problems at other levels. You will be suprised how things change when you break down the faceless ins. companies to actual people.

Good luck

Pat

NCFUSED · #4 01-10-2005, 09:44 PM

My degeneration is worst at the L5/s1 level according to the extremely painful discogram I had during Thanksgiving weekend.

I actually have 2 more levels that are mildly degenerated, but not causing pain right now. I have done the 6 months of recommended PT, Drugs galor,(ie Neuronton, pain killers, anti inflammatories), a lumbar epidural that made me more sick than it did a thing to releive my pain...

So I have been waiting since early December to have my ADR surgery.

Can anyone tell me how long the appeal process had taken them??? I know all Insurance Companies are different. My last hope before fusion will be to appeal to the NC Board of Insurance.

Thank You Very Much for the Support and Answers!
John
38 Y/O Male
Greensboro, NC

Harrison · #5 01-11-2005, 08:58 AM

John, the appeal process varies in length. I'd say the extreme ranges (for a complete end to end process) is from 1 to 12 months. Perhaps the average is app. 3 months. But here's another funny way to look at the appeal process duration in terms of your approach:

1. Insurance appeal only: 2 months
2. Insurance appeal, state insurance comm.: 3-6 months
3. Insurance, state comm. and legal help: 8-12 months (or longer!)

These are "loosey goose" numbers based on anecdotal info, by talking to other folks from the board.

Do as much work up front as you can, but don't let them dictate your health. I didn't wait for some beancounter to say "yes" to ADR and had it done prior to recieving authorization for reimbursement. It's a lot of money, but it was worth it! I have my life back!

Do you have a letter of medical necessity yet from your doctor? Have you spoken directly with the people in the appeals dept. at your insurance company -- and followed their process? There's a lot to do, unfortunately.

NCFUSED · #6 01-12-2005, 11:27 AM

Thank You,
Not encouraging news. I am hoping my 1st appeal gets some attention. My Doctor is filing it directly....

John

JeffreyD · #7 01-12-2005, 11:31 AM

...........what about getting overseas ADR paid for by U.S. insurance? Anybody had any success with this, and if so, how did you do it?
thanks,
Jeff

Harrison · #8 01-12-2005, 11:58 AM

Jeff, a few people have had ADR overseas and been reimbursed by insurance. Generally, I believe reimbursement is comparatively easier to get stateside -- but one must pick their battles!

gary · #9 01-13-2005, 09:58 AM

i am a 2level prodisc surgery patient, my Docs office had no problem getting approval for my surgery, in fact they had approval in 5days, which shocked the heck out of me, as i was told by them it may take months. later i found out since i am in the trials they got approval for a
2 level fusion, as it was possible this is what i could have ended up with. Evidentually these 2 types are basically the same, since i was in the trials the implants were of no cost to me.
gary