Looking for Precedents

[Researcher]

Hi everyone! My name is Phil, and I am new to the forum. I decided to post my introduction here, since I'm going to jump right into needs I have related to insurance.

I have multi-level cervical degenerative disc disease and am preparing to battle with my insurance company, BCBS-AL, to cover the cost of going overseas to have M6-C discs implanted. I have not finalized my surgeon choice, but I'm 90% sure at this point. I've been studying, talking to lots of surgeons and patients around the world, participating in multiple forums for several months, and most recently, have been coached by Laurie Todd (http://www.theinsurancewarrior.com) as I prepare my draft appeal.

I know there are patients on this forum that will be able to help me. I'll swim around and find you eventually. In the meantime, I would love to hear from any of you that happen to find me first! Below is my standard, "Help, I need big surgery and can't pay for it" appeal that I have been posting around the net. I provide an email address below, but feel free to PM if that is more convenient.

I look forward to making some new friends here. Have a great day, and don't take too many pain meds!

************

I am preparing an appeal in anticipation of denial of coverage by my insurance company for artificial disc replacement surgery (ADR). I am collecting information for the precedent section of my appeal. If you were approved by your insurance company for ADR, I would greatly appreciate the following information.

First Name, Last Name
Surgery Date
Diagnosis: e.g. herniated disc at C6/7
Treatment: e.g. ADR at C6/7
Insurance Company that paid
Surgeon that performed ADR

Many ADR patients desperately need this information to support their appeals. If you do not mind me sharing this information with other patients making appeals, please state this in your email. If you would prefer not, I will honor your request and keep the information private. You can forward the information to the following email address.

adrpaidfor@comcast.net

If you would like to communicate with me first to develop a comfort level that I am just a regular guy trying to get what I should from the insurance company and help other patients at the same time, please send a note to the same email address.

Thanks,

Phil

[JPJH]

Hi Phil,

I wish you all the best with getting your insurance to pay for you ADR. It's a tough road ahead, but hey someone has to fight the good fight. Personally I just got tired of the fight after two years of dealing with my insurance, appeals, etc..

I just got home from Barcelona this week where I had two level c-spine (4/5 & 5/6) ADR using the M-6 with Dr. Clavel. Happy to say all went really well and I'm feeling great. Dr. Clavel was great to say the least and the Quiron Hospital was top notch. Spent two nights in the Hospital and then a week and a half having fun running around seeing the sights in Barcelona.

Again all the best to you for a succesful outcome.

JPJH

[jss]

Originally Posted by JPJH

... Personally I just got tired of the fight after two years of dealing with my insurance, appeals, etc..

I just got home from Barcelona this week where I had two level c-spine (4/5 & 5/6) ADR using the M-6 with Dr. Clavel. Happy to say all went really well and I'm feeling great. Dr. Clavel was great to say the least and the Quiron Hospital was top notch. Spent two nights in the Hospital and then a week and a half having fun running around seeing the sights in Barcelona.
...
JPJH

Congratulations on your excellent outcome! Dr Clavel did two level for me one year ago next month. Sounds like you're having an excellent outcome!

Good luck, Jeff

[JPJH]

Jeff,

Thanks! I feel very lucky that things went as well as they did. As we all know the outcome of any surgery is uncertain. I still have some healing to do and some of my aches and pains do remain, but should/may improve as the healing process continues. Dr. Clavel said should be 6 months up to a year. It's hard to know how much of the damage to nerves, etc. will go away. I've dealt with this issue for 15 or so years. But I can tell you that the burning pain I had that ran down the left side of my neck, shoulder, arm and hand is gone. That in itself has been a huge relief. That was the symptom that just used to drag me down and wear me out. So it is gone, I hope for good. Again time will tell.

JPJH

[danzintommy]

Phil,
My name's Tom.
Had a fight with BUPA international to get pre-approval for L4-5 Disc replacement and possible L5-S1 Fusion (or poss replacement).
The orginally denied cover, saying it was a pre-existing condition. Part from getting help from Specialist and GP, I also discovered the Financial Ombudsman - UK who oversee UK based insurance companies (like BUPA). Their site is Financial Ombudsman Service
On that site I read a lot of great info as to what can and cannot be denied by insurance companies (at least UK ones). I'm glad to say I didnt have to go to the ombudsman, and BUPA agreed to cover when I challenged them and laid out all the pertinent facts. (I sent them a bit of a novel!)

Anyway- they recognise the surgery and I think only denied as a way of trying to limit payouts.

Hope that helps.