MY insurance definitions...

[symara]

Ok, so I read the Insurance Warrior's book and was looking at my definition for what will probably come with my denial (I work for my insurance compnany)

It will be denied experimental and investigational so according to my plan it has this definition:

Experimental, investigational or for research purposes

:

means a drug, biological product, device,

treatment or procedure that meets any one of the following criteria as determined by the

Plan Manager:

1. Is identified as not covered by the Health Care Finance Administration Medicare Coverage Issues
Manual as experimental;
2. Cannot be lawfully marketed without the final approval of the United States Food and Drug
Administration (FDA) and which lacks such final FDA approval for the use or proposed use, unless
1) it is found to be accepted for that use in the most recently published edition of the United States
Pharmacopeia-Drug Information for Healthcare Professionals (USP-DI) or in the American Hospital
Formulary Service (AHFS) Drug information, or 2) it is identified as widely used and generally
accepted as effective for the proposed use as reported in a national database of peer reviewed medical
literature published in the English language as of the date of service;
3. Is a device required to receive Premarket Approval (PMA) or 510K approval by the FDA but has not
received a PMA or 510K approval;
4. Is not identified as widely used and generally accepted as effective for the proposed use as reported in
a national database of peer reviewed medical literature published in the English language as of the
date of service; or
5. Is subject of a Phase I trial or is otherwise under study to determine its maximum tolerated dose, its
toxicity, or its safety.

I will address each one and tell me what you think...

1. Medicare has only addressed the issue for those over 60, right? so this does not pertain to me since I am 30.

2.N/A - FDA approved

3. N/A

4. I just need to get some peer reviewed articles, right? What has everyone else used? What is suggested?

5. N/A

[Harrison]

Sym -- just to touch on one of your questions on peer reviewed articles. Both Synthes (ProDisc L,C, Nova, etc.) and Depuy Spine (Charite', Discover, etc.) have resources and people to help with your appeals. In their documents, on their respective web sites, you will find some (outdated) bibliographies. I assume Medtronic does too; but I've not had the time to retrieve their information.

A little help from the community would be great!!! Recent appeal whizzes?!

[Jdouglas]

I have a copy of all of the case studies that UHC refers to in their rejection. I am just not sure how to post all of them? Harrison, any suggestions?

-----------------------------------------------------------------------------
L5S1 Herniation and Annular tear
Over 10 epidurals,
DDD, 2 discograms (positive),
Countless attempts at conservative therapy.
Surgery date 5-26-09

[Harrison]

J, do you mean the cases the insurance company used to DENY coverage? If so, that's not what patients need to argue for coverage, but these would be helpful and interesting for other reasons. You can email or fax to me, then I can post them...

[Jdouglas]

Harrison, these are the ones used to DENY coverage. I think you will find that they are the same studies that are used to support ADR by other insurance companies. The difference is only in the conclusion at the end that UHC reached or what methodology they use to delegitimize a particular study (not enough participants, not randomized, etc.). As such I think that these are important in understanding how an Aetna treats the same study vs. how UHC treats it. Some companies look at the info and what it says about a treatment while others look for loopholes and flaws to knock a study that doesn't agree with their decision. Essentially I think the business decision is made and then whatever information supports the decision is bolstered and anything that counters it is attacked. A "let's not cloud the issues with facts" approach if you will. Shoot me a private note with your fax number and I will send it over Monday morning.

-----------------------------------------------------------------------------
L5S1 Herniation and Annular tear
Over 10 epidurals,
DDD, 2 discograms (positive),
Countless attempts at conservative therapy.
Surgery date 5-26-09

[Jack]

I would be curious to know what rationale they used to determine 60 y.o. was to old. I hope the fudge it a little if it is for a bright eyed country boy who can sing a little but not dance a lick. Seems I heard that before about the same thing about this guy that danced with Ginger Rogers.