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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 04-12-2009, 11:44 PM
Sooner Sooner is offline
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Default Approved for ADR by Empire BCBS!

I just found out last week that my husband's company approved my disc replacement with a Prestige Cervical Disc. I am scheduled to undergo an ADR at C5-C6 on 4/14. My husband purchased Laurie Todd's book "The Insurance Warrior" and wrote a blockbuster appeal using her methods. It was well worth the $18. He cc'd copies to Empire BCBS, his company's HR department, and his brother-in-law who is an attorney for the 2nd level appeal. We're not sure if Empire even bothered to read the 80 page appeal but it must have impressed someone in his company's HR department because they overrode Empire's 2nd denial and agreed to cover it as "in network".

His company's plan is self-funded so they have the final say on coverage. My husband was optimistic that the HR department would side with us and he was right! My advice to anyone who is fighting this battle with their insurer that before you write your appeal, purchase Laurie Todd's book and use her methods. This process has really opened our eyes to how health insurance plans really work when you have a potentially expensive health problem such as disc replacement or, God help you, cancer.

The good news about self-funded group plans is that your employer pays for your health care and have the final say on what they will pay for. The bad news is that these types of plans are covered by a federal law (ERISA) and your only recourse is to file a complaint with the Department of Labor to force your employer to pay for treatment. You cannot sue for punitive or monetary damages. The only thing you can win is your treatment. But what good is this to anyone if you are dead? Because of this, most attorneys won't even want to take your case because there is no money in it for them. The system is stacked in favor of the insurer and the employer and therefore they have no incentive to pay for treatment if they don't want to. You are literally at the mercy of your employer to do the right thing and pay for your treatment. There are instances where the employer finally approves your treatment but by that time it may be too late to do any good (i.e. cancer). Thank God my husband's employer agreed to do the right thing and pay for my treatment.

Group or individual plans that are not self-funded are not covered by ERISA and you do have more legal recourse if the insurance company doesn't want to play fair. You can sue for damages and file a complaint with your state insurance commissioner. The bad news is your employer has little or no influence with the insurer to convince them to pay for your treatment since it is the insurance company who is paying for your treatment.

The main point I want to make is that you or a family member need to be the the one in control of the entire appeal process. You must be polite, proactive and assertive if you want the best care possible! Don't just assume that your surgeon or his staff will do it for you. If your surgeon, doctor, lawyer is any good then they will be too busy to do it all for you.

Good luck to all who are still fighting this process. At times over the last six weeks I felt like giving up and agreeing to have a fusion just to get it over with. I'm really glad I hung tough and saw it through to the end!

Please keep me in your thoughts and prayers over the next few weeks. I will try to post again soon with an update on how everything went.
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  #2  
Old 04-13-2009, 03:59 PM
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Harrison Harrison is offline
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Default Congrats!

Well said, and thanks for sharing your insights! When you get a breather, please send along the confirming approval documentation to me.This will help other people as well. Good luck with the steps ahead! See this topic:

Archiving of Successful Appeals

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Fell on my ***winter 2003, Canceled fusion April 6 2004
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Old 04-13-2009, 05:43 PM
JJames JJames is offline
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Thumbs up Bravo to you on your victory! Best of luck on the surgical outcome!

Sooner,

I too work for a company whose medical insurance is self-funded. Since I have worked for the company for about 20 years, and actually speak fairly often with the owners of the company, I thought for sure that my surgery would be covered. Boy was I wrong! How disappointing when money is so much more important to business owners than the well-being of even long-term loyal employees! I was given the excuse that they would be setting a precedent for any other company employee who was requesting a procedure which is not currently approved by the FDA and considered experimental in nature!

I am very angry and saddened by my treatment from my employer(s), but very happy for you. I wish you nothing but the best going forward!

Jeff
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DDD diagnosed ~99
Chronic Pain since Aug 2006
Failed L4 Microdisctectomy Apr 2007
2008-Positive Disco (L4/L5&L5/S1 annular tears)
Herniated discs at L4/L5/S1, bulging T12
Began constant/severe neck & upper back pain 11/09
Jan 10-Cervical/Thoracic MRI:bone spurs+new disc probs
Cervical Spine issues causing terrible pain beginning in July 2021 - scheduled for 2 level C-Spine ADR on Oct 19th 2021 now!! Part of Clinical Trial so unsure if Mobi-C or Baguera C will be implanted ....
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Old 04-15-2009, 10:20 PM
ans ans is offline
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Default Great!

This is fantastic news and your hard work paid off. Too bad most are denied.

May I ask what state Empire/BC was in? I have them for NY and I've been told by my ADR doc that they most definitely will deny.

Best of luck. - Allan
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Severe, extensive DDD, considered inoperable by Dr. Regan, Lauressen, & some guy at UCLA. Severe foraminal stenosis (guess they can't operate!) and some spinal cord compression that Lauryssen would fix if gets outta hand.
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  #5  
Old 04-16-2009, 06:59 PM
kimmers kimmers is offline
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Default

Sooner,

Congrats. Good explanation of ERISA.

Kimmers
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Old 04-17-2009, 08:06 PM
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Harrison Harrison is offline
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Talking ERISA, tigers and bears oh my...

"...The main point I want to make is that you or a family member need to be the the one in control of the entire appeal process. You must be polite, proactive and assertive if you want the best care possible! Don't just assume that your surgeon or his staff will do it for you. If your surgeon, doctor, lawyer is any good then they will be too busy to do it all for you..."

Sooner, thanks for your post – this excerpt hit all the nails on the head! For what it's worth, Medtronic’s appeals department has their own employees (rather than outsourcing or partnering) and will assist at all stages of a one-level (single level ADR) insurance appeal. Their success rate is reportedly 80%, which seems remarkably high – especially since it saves the time, cost and frustration of having to hire an attorney. I believe they may assist with two level (off label or compassionate use appeals), but not with the same level of commitment as a one level (for a long list of reasons).

BTW: Anyone that explains ERISA that succinctly is a gifted teacher, government bureaucrat or an extraterrestrial!

Thanks for sharing.
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Fell on my ***winter 2003, Canceled fusion April 6 2004
Reborn June 25th, 2004, L5-S1 ADR Charite in Boston
Founder & moderator of ADRSupport - 2004
Founder Arthroplasty Patient Foundation a 501(c)(3) - 2006
Creator & producer, Why Am I Still Sick? - 2012
Donate www.arthropatient.org/about/donate
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  #7  
Old 04-21-2009, 12:05 AM
Sooner Sooner is offline
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Default Surgery Update

My cervical ADR went very well on Tuesday last week. My surgeon was able to remove my disc in 2 large pieces which is ideal. He installed the Prestige cervical disc made by Medtronic. I was back home recovering the very next evening. I'm still experiencing some postoperative pain but the numbness in my hands, fingers and legs was gone just a few hours after surgery. My pain is dissipating noticeably with each passing day. On Saturday I attended my kids' sporting events. On Sunday I was able to transition from my strong dose pain medication to a smaller dosage and today went without taking a muscle relaxer. My brother underwent a fusion about a year ago and can't believe how well and quickly my recovery is progressing. I am looking forward to my appointment with my neurosurgeon on Thursday for my post-op exam.
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  #8  
Old 04-22-2009, 10:24 PM
ans ans is offline
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Default Fantastic news

It really is and I hope that this w/be a permanent "fix" to your cervical problems.

Best, Allan
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Severe, extensive DDD, considered inoperable by Dr. Regan, Lauressen, & some guy at UCLA. Severe foraminal stenosis (guess they can't operate!) and some spinal cord compression that Lauryssen would fix if gets outta hand.
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  #9  
Old 04-23-2009, 10:52 PM
Sooner Sooner is offline
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Default Follow-up with neurosurgeon

It's been 9 days since my cervical ADR and my I've been cleared to drive by my neurosurgeon today. He also cleared me to return to work next Wed which will be 15 days after my ADR! Even though my overall energy level is still not yet 100%, I'm absolutely amazed at how quickly I've recovered. I'm confident that my energy level will return to 100% over the next 3 weeks. Anesthesia is really tough on the body. I will have another follow-up exam in about 4 weeks and get an X-ray of the replaced joint C-5/6.
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  #10  
Old 07-16-2009, 04:20 PM
lkkoh lkkoh is offline
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Default ADR surgery?

Hello Sooner,
Which surgeon and hospital did you have your surgery done?
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2009 diagnosed with:
- C3-4 and C4-5 cord compression
- C3-4 and C4-5 neural foraminal encroahment bilaterally
- C-3-4 and C4-5 DDD Spondylosis
Symptoms:
- Neck aching, discomfort
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