Community generated Insurance Appeal Letter

[Mariaa]

Altho my WC insurance carrier has authorized payment for ADR surgery (2 level trial) twice and I haven't had it done, I did receive a Non Certification when it went thru Utilization Review Appeals Procedure Worker's Compensation-California. Here is the reason:

Disc replacement is not consistant with ACOEM guideilnes. This is a clinical trial and no long term studies are available. Non certify.

[DWebster]

Harrison there is no such thing as a unconstructive response, right now we need all ideas and thoughts on this matter from everone. it would be easier if we we all in conferance room working on this but we don't have that luxury.

Cavalier,
Would your sister inlaw consider helping us off the record, an insider would give us a great advantage.

Keep them coming and then in a couple of day we will try to sort out what we need to use. Any Legal help would really be great!!

[Patrick]

As I mentioned to Nichole in her "appeal in person granted" thread, The Artificial Disk Study in the Professional Articles section has a bunch of great information and comparisons between fusion and ADR. It also stated some ADR posititive long term results from other countries.

[cavalier]

DWebster- ALL my sis-in law has added to this is the fact that what is more cost effective is not the issue. THey also do not care about the costs involved with apprvoed med's or the risks to the patient in their long term use.
If they can get by without paying by saying experimental or not enuf long term data they will. They are not there to pay for every claim that comes in willingly. The fact that they would have paid 150K for a 2 level fusion also is just how they do things so cost savings is not ironically an angle.

The only hope is saying to ask for a exception based on medical necessity & the fact that this surgery is the same prep work required as in a fusion or Charite ( I had P.D.) & that to ask they pay for all but the device then since it is the same prep work & to keep hanging in there. If bothered enuf & it may require an atty. & the threat of a jury trial - maybe in time at best they may offer a partial settlement. We were not turned down until after my surgery & we had gotten back home - we had a case number & they sounded encouragaing this was not a problem, although they never said offically yes.

Jill L4L5 P.D. Dr. Bertagnoli Straubing Germany

[Paul]

Originally posted by Harrison:
[qb] which they report is:

[snip]

- inconclusive,
- resultant from what they perceive as "flawed" or imperfect trial designs (from Europe),
- actually decidedly poor, in that early designs of devices (techniques and designs were truly experimental and certainly prone to high risks) resulted in complications and failures.

[snip]

[/qb]

Seems like they are trying to have it both ways. They are saying they will only use US data on the efficacy of ADR and yet use old European data to prove their denial. With that logic I don't see why they don't deny brain surgery as the Inca's tried it and their patients usually died. Geez.

Also, I'm curious about the 2 reports that has Harrison has linked above. These seem to be presentations giving to professional meetings. Are these presentations then actually published in a journal somehwhere? I can see that being a sticking point as they can say this wasn't actaully published and not subject to a true peer review. Just my thoughts as I don't know the answer to this.

[DWebster]

Does anyone else have any ideas as to what we should put into the letter? I am soory I have nto been on more but it is getting realy hard to sit in front of the computer. I had a ESI today adn I hope in a few days I will be able to do more. well thisis the most I can stand for right now. if people would like to start researching for the ideas we have please do so.
Thanks every one.
DAve

[patty]

Hi all,
I am a newbie here but I am starting the process of figuring out how to appeal. I have been denied approval for the 2-level( L4-L5, L5-S1) ADR by phone.
I would like to join this effort.
I have a friend that is a statistician, runs a consulting center and has spent 2 years in Sweden working with a major university dealing with European data. I will ask him if there is a technique used for Analyzing European data that can account for "design flaws". It is worth a try.

Patty in Dayton, Ohio

[KevinSF]

I have my denial letter in front of me from Great West Health Insurance.

"We have denied your request because based on the clinical information received, the proposed procedure shows promise in this setting but is investigational and not yet approved by the FDA or supported by published peer-reviewed literature or scientific medical evidence. Investigational procedures are specifically excluded under the benefit plan..."

Although they clearly state that -no FDA approval - no ADR approval - they also seem to imply that if I had some "clinical peer data" that perhaps they would consider it????

[ans]

I think Patty is on target.

Maybe one reason for insurance trepidation is that the European retrospectives are both dissonant and one study reveals poor results - reportedly as a function of physician acumen (placing/sizing - I think acc'd to Mark).

But what kinda track record does fusion have? Not great.

I contradict myself; sorry.

[KevinSF]

Since I am in the middle of a fight with Great Worst Health Insurance - I received a new fax today from them. It was a 2+ page policy report on Interertebral Disc Prosthesis.

They include a lot of references to the succes of ADR but their policy states "...not covered since it is considered experimental"

and here is the info regarding the FDA approved Charite: "Despite it's approval by the FDA there is insufficient evidence available at this time to determine the efficacy of the procedure as a treatment for degenerative disc disease compared to standard treatment/ Controlled studies on artificial disc replacement in sufficiently large patient populations with longer-term follup are necessary to draw definitive conclusions about effectiveness, especially compared to competing procedures such as spinal fusion. Based on this assesment the procedure is STILL considered experimental and investigational and your appeal is DENIED."

Nice - the FDA trials were enough for our government but not for Great West...

I am at a dead end with them and I am in so much pain I can't wait any longer.