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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 08-01-2014, 01:44 AM
Iron Iron is offline
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Join Date: May 2014
Posts: 13
Exclamation Final appeal

Hi, just wanted to check to see if anyone had some input and/or advice for me in writing my last appeal with Blue Cross of Idaho to have an artificial disc surgery done.
First off, I am a healthy 44 year old gym owner and trainer. Never have had a surgery and have always kept in super shape. I am about 12 percent body fat. I have zero pain. I am just super weak on my right side...only in my deltoid, bicep, rotator cuff, and forearm (grip).
I have been diagnosed with C 5 Radiculopathy.
Here is where it gets interesting. MRI shows multi level issues. Iam oly symptomatic at the C 5 level.
They are denying me because they say that it is experimental because I have multi level degenerative disc disease.
On their page it clearly states that they cover the surgery for folks that have DDD and re symptomatic at only one level.
Thanks for any help at all.
__________________
Body Builder/Trainer
C5 Radiculopathy- with only major weakness in right bicep and deltoid, no pain. Unacceptable
Insurance denial of ADR
Grade 2+ spondylolesthesis at L5/S1 (I can deal with the pain as long as I am active)
May 8 2015----3 Level Cervical ADR @ C4-C5-C6
With Dr. Clavel
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  #2  
Old 08-01-2014, 07:05 PM
Kelly4ADR's Avatar
Kelly4ADR Kelly4ADR is offline
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Join Date: Jan 2014
Posts: 259
Default

Hello,

I am currently appealing Aetna for a two level cervical. This is my third and final appeal over the last 6 months. The determination is due to come no later than Aug 9 via a letter in the mail...

I'm not completely familiar with BCBS ' appeal process. How many appeals have you sent so far and what did they include? Were they all denied for the same reason or did they change reasons? Has your surgeon been involved in the appeals process? Their denial doesn't make sense, unless you haven't met some criteria, for example, Aetna states you must have failed at least 6 weeks of conservative therapy...

I also have multiple cervical levels (5) but I need a two level replacement at c5-7. Do you know what prosthetic your surgeon is requesting? Are you sure his CPT codes didn't include more than one level? It sounds like the denial is for requesting multiple levels??

I have been blessed to have a company...MCRA... Handling my case and submitting appeals on my behalf, as well as my surgeon. If you want to send me a PM with your email I am happy to share my appeal documents with you.
__________________
2004 MRI -cervical bone spur causing pain
2011 MRI -5 bulging discs at C3-7: Recommended C5-6 and C6-7 for a two level fusion, I said no thanks.
2014 MRI -progressive compression C5-7.
MRI 6/5/14- Ruptured L4-5, bulge at L2-3 and L5-S1 Dr recommends discectomy of L4-5 but won't do surgery until cervical is stable
8/2014- 8 months/3 rounds of appeals, Aetna denies 2 level cervical ADR
2 level ADR w/ mobi-c C5-7 Jan 7, 2015

Last edited by Kelly4ADR; 08-01-2014 at 10:47 PM. Reason: I hate typos
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  #3  
Old 08-01-2014, 10:43 PM
Kelly4ADR's Avatar
Kelly4ADR Kelly4ADR is offline
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Join Date: Jan 2014
Posts: 259
Default BCBS Idaho medical policy cervical ADR

I looked up the medical policy intervertebral discs cervical for your insurance. It looks like you have to jump through some hoops and it does say you can have one disc replacement if you have SCDD (symptomatic cervical disc degen) at only one level, not multiple. It doesn't say you can't have DDD at other cervical levels, just no other symptomatic cervical levels. So, being that it looks like they want all kinds of documentation to approve one level, have you had any tests to conclude, with all certainty that your symptoms are from that disc? Like a discogram? It seems like if you could prove the other levels are not producing any of your symptoms they don't have a reason to deny. That doesn't mean they won't, though...rarely does it make sense what they do
__________________
2004 MRI -cervical bone spur causing pain
2011 MRI -5 bulging discs at C3-7: Recommended C5-6 and C6-7 for a two level fusion, I said no thanks.
2014 MRI -progressive compression C5-7.
MRI 6/5/14- Ruptured L4-5, bulge at L2-3 and L5-S1 Dr recommends discectomy of L4-5 but won't do surgery until cervical is stable
8/2014- 8 months/3 rounds of appeals, Aetna denies 2 level cervical ADR
2 level ADR w/ mobi-c C5-7 Jan 7, 2015
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  #4  
Old 08-01-2014, 11:32 PM
Iron Iron is offline
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Join Date: May 2014
Posts: 13
Default Impressive thinker

Hi Kelly,
Wow, you are very sharp on this stuff. I am praying for your successful appeal. I just requested yesterday a Discogram from my surgeon. He said that it was very controversial and a waste of time. I think I am switching surgeons. I am also trying to get a cat scan. Cheezeeee,, I am super healthy in all other areas of my body... And I never use my insurance. Soooo frustrating. Thanks for all of your help... You are so appreciated.
Mike
__________________
Body Builder/Trainer
C5 Radiculopathy- with only major weakness in right bicep and deltoid, no pain. Unacceptable
Insurance denial of ADR
Grade 2+ spondylolesthesis at L5/S1 (I can deal with the pain as long as I am active)
May 8 2015----3 Level Cervical ADR @ C4-C5-C6
With Dr. Clavel
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  #5  
Old 08-02-2014, 12:01 PM
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Kelly4ADR Kelly4ADR is offline
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Join Date: Jan 2014
Posts: 259
Default

Thanks for your prayers Mike...as this week approaches I'm a bit rattled. I will have surgery either way, if it is still denied my insurance will pay for 1 level and I'll pay for the other, about 16k out of pocket, but it's the principle for me...I deal with insurance with my massage clinic and we are seeing denials come across more and more for very non legit reasons. It's a delay tactic that really makes me mad. I have to spend more and more money to have my staff push papers back and forth to get even massage tx paid. I personally have put off surgery for many many years, for them to tell me now that I can't be allowed what I need? Frustrating is an understatement...and I feel like we owe it to those coming up behind us to fight to get approvals and pave a path for them. Insurance has to be consumer driven as much as we are able or it will only get worse. Wow, sorry for the rant as I look at this big paragraph lol. Enough about that!

If you are considering switching surgeons, look up Dr. Richard Wohns is Puyallup, Wa. His clinic is Neospine. He is my surgeon. If you are in Idaho he isn't all that far from you and worth the travels. He is in south Wa, I am north Wa and it takes 2-2.5 hours for me to get to him but he is truly an expert in this area. If you look up his credentials it is impressive. At least he could be another opinion for you. They are also very pro-ADR and will work on your behalf to help with insurance approval.

I have never had a discogram but I've heard they are not fun. But I've also heard they are a valid test to conclude the source of symptoms. Hobbes1212 has had 3 cervical ADRs done by Dr. Wohns (1 in one surgery and 2 in another). He performed discograms on her to validate. I feel that if he uses this test, it is valid as I trust him very very much. But, maybe he would have another suggestion as well, he is the expert. He may even do a review of your films without having to travel over. There is another poster on here (CDW...) who is in NY who is sending her stuff for his review I believe. I also got opinions from overseas Docs, Clavel and Bierstedt (sp?) who will review your stuff for free. The more opinions you can get, the better.

I hope this was helpful
__________________
2004 MRI -cervical bone spur causing pain
2011 MRI -5 bulging discs at C3-7: Recommended C5-6 and C6-7 for a two level fusion, I said no thanks.
2014 MRI -progressive compression C5-7.
MRI 6/5/14- Ruptured L4-5, bulge at L2-3 and L5-S1 Dr recommends discectomy of L4-5 but won't do surgery until cervical is stable
8/2014- 8 months/3 rounds of appeals, Aetna denies 2 level cervical ADR
2 level ADR w/ mobi-c C5-7 Jan 7, 2015
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