Community generated Insurance Appeal Letter

[DWebster]

Welcome everyone,

Here is my idea, for most of us the biggest problem has been getting the insurance companies to pay for ADR surgery. For many it has come down to appealing the insurance companies� decision. I would like to generate an appeal letter that has been worked on by the whole community. By doing this, we can gather more ideas, documentation and thoughts. The first thing we need to do is brain storm, having everyone submit their ideas and thoughts. Remembering no ideas are bad and none should be criticized!! This is very important or people will begin to be afraid to submit there ideas.

After we have decided what should be put in the appeal, documentation should be gathered to support the ideas. People can choose an area(s) that interest them or where they have already gathered good documentation. We should gather everything we can. My idea is not to make this a large document, but one with the effective points bulleted. So the more information we have, the better selection will be. As you enter your ideas and information assign it a number. This will make it easier for others to comment on. Just increment your number by one after the entry ahead of you. Again, remember this is just a brainstorming document. Please do not criticize anything!

After WE ALL have decided that we have all the information we need we can then try to assemble it. My idea is to not make this a huge document. I am a testing engineer and use different ways of submitting data. One of the ways is burry the information I don�t want to be noticed. An example of this would be, if you do not want something to be found, include it, but spread it out and cover it with fluff, I do not think this is what we want to do, and that is what can happen if a document gets to large. In my opinion, I think a document set up like a resume would be very effective. List all the facts up front and right to the point with references to the facts (incase they are questioned) in the later part of the document. We do not want them to just glance at it and then throw it aside. We are going to need someone or someone�s that have good writing skills to pull it all together. I can help draft it but I do not fell my writing skill are the best.

After we have the ruff draft together we need everyone to constructively comment on it. This should be done after each revision. If there is a disagreement on what should be put in and can not be resolved then I think Harrison should have the last voice in the matter but I don�t think this will be a problem. As a community we have a vast amount of expertise and knowledge to draw from. The last thing would be to have someone with legal knowledge to look it over. I real think this can be outstandingly effective and useful document.

I would like to thank everyone in advance for the work that you will put into this. For some the only reward will be that you have help our extended family, and for those that it help will extremely grateful

Dave

[Harrison]

thx for taking the initiative, Dave, and making this a priority!

Pls folks, any and all ideas are welcome. In the meantime, I'll summarize the two post recent study findings I posted here, as they are significant -- and may have already played a role in these "secret" negotiations between the medical and insurance organizations!

[DWebster]

Yes Thanks Harrison these are very good documents that we should use, they will help prove the argument that ADR is superior to fusion the so called gold standard. These will be of great use. That has been one of the insurance companies agruments that there is not enough info to prove that it is better. the second part of there excuse has been they do not know the long term effect. we should be able to get this from overseas data. The have been performing ADR there for 15 years, I think that should be considered long term data. Lets keep it coming folks, this is going to be a great project.

[DWebster]

Lets get this started.

please list the reason people have been turned down.

1. I have heard that the insurance companies say they do not know the long term result form ADR: This has been done overseas for 15 years, thre has to be data someplace on how these people are doing.

2. information on the comparison between ADR adn fusion form the trials: this we should be able to get from the Information that harrison provided.

3. Cost of Fusion VS ADR, this should include operation, hospital stay, thearapy, meds, ect.

4. average for further surgery from effect of first (hope I said that right)

5. not they realy care but how have patients graded each surgery.

Please folks help out here.

[Cat-mt]

Webster, thanks for getting this started.
The reason given from my insurance company is as follows: That regulations and program policies restrict benefits to those devices, treatments, or procedures for which the safety and efficacy have been proven to be comparable or superior to conventional therapies. Any device, medical treatment, or procedure whose safety and efficacy has not been established is unproven and is excluded from coverage. I spent one hour on the phone with the insurance company on friday to get their defination of UNPROVEN, and no one could give me that information. I feel like i'm running in a circle and everyone has a stick and they are taking turns hitting me. I went to the hospitals medial libiary and pulled a bunch of info. One thing that needs to be in the letter is the cost of meds. I take Avinva 120 mg at a cost of $507.69 a month, we need to put in the average cost of meds. I have a friend that works at a pharmacy if I get a list of meds from everyone I could get the price for all of the different meds. I'm not working so if there is anything that needs to be done in the way of research or anything at all just let me know.

[DWebster]

Very good!! Can people please list the meds and quntity they take so we can try to come up with a average, even better yet would be anyone that has had fusion and rembers what they had taken. I am sorry to say this but can some put the denial into words we can all understand, this is realy not my field.

[Nichole]

SUGGESTION #2

Webster, I am taking 60mg of avinzia per day, 600 mg of neurontin per day, 110/50mg of Atenol/Chlor per day. I will have to let you know at a later time the cost per month of all my meds. Or if Cat-mt could check with her friend on those prices that would be very helpful. I dont have that info at the moment. I have had 6 ER visits in the last year for break thru pain treatment at approximately $875.00 per visit.

I am doing some research on fusions and the effectiveness of that surgery. I think adding information that is quoted from litertaure on the negatives from the fusion vs. the positives of the ADR would possibly be helpful.

more suggestions to come later, time for bed

[cavalier]

Hey there the basis of my denial has been EXPERIMENTAL & they do nto care about paying more money for a fusion or for med's. I have a sis in law who works for BCBS ( not in my state) & she too echoes as she is one of those who decides what they will or wont pay. They go for the gold standard fo what the FDA has approved but the procdeutre for a fusion or for ADR in preping the body is the same OTHER than the device so my arguement is pay ONLY for the surgery & NOT the device. Also BCBS has paid for others to have had this surgery BOTH P.D> & Charite so I am saying they can not pay for some & not others. Since my surgery was emminent & medically necessary they would have had to pay for a claim regardless. I am saying if they continue to deny this is my 3rd appeal I will have the expense of an atty ( which they can stall us for some time since they ahve atty's on staff) but when we go to court I will request a jury trial & also request extra money for the time & expense of an atty & the dealy in having them pay. I say pay all but the device of my surgery which was 21,5 K overseas at the International rate- I know it is silly as they would have paid up to 150k for a 2 level fusion - as the level above already herinated & torn would have had to have been included then in a fusion. They already have my MRI info - I am not normal in any of my lumbar discs but again it is NOT what makes good sense but it is whatever they can wriggle out of paying - however the fact is they would have paid more they do not care about. NOR do they care that this procedure gets one up & around sooner etc.
Hope this helps - Jill

[cavalier]

OOps I forgot to add I have a newspaper article I found by doing an search on the web - it states that BCBS is paying for CHarite ADR surgery in Fl & lists the doc & the hospital they are paying 50 K to 75 K for the same thing I had done except my device is diferent so they do pay for this procedure - I sent it in with my 2nd appeal & they have it on record - I am saying you are paying much more than what I am asking to be refunded to us. I am allowing them to exclude paying for my disc itself but obviously the surgery is the same so pay for it - I was still denied. I go for my 3rd appeal in person this Thurs. What you want is clear cases in writing published of where they have paid with the insurance companies named. Suggestion would be for more to search for such articles & compile them. I am short on time now as I have to prepare to leave I have to dfrive 6 1/2 hr's each way - so conveienent of them isn't it ? Plus much to do before I go -
Jill

[Harrison]

Folks, I think we need to give more thought to the "construct" or outline of this before we ask for things like price of medications (which we know are pricey!).

The main reasons why insurance companies are avoiding reimbursements are something like this:

1. Their policies dictate that "experimental" technologies are unproven; this is partly defined by the "legality" or approval of devices by the FDA. The other part of the experimental definition in their policies is driven by long-term efficacy data, which they report is:

- 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.

2. They are insurance companies, who strive to retain their market power and ability to make profits. Accordingly, their incentive for changing policies are not aligned to ours, by any means! Their policy changes need to go through layers and layers of bureacracy!

The rational for effectively arguing for long term efficacy and cost savings makes sense to folks here, but the approach (construct or outline) of this proposed document is everything. I know this comment is remarkably unconstructive, but perhaps our member friends in the legal world can give us some guidance. Bill, Leanne, others who have have first-hand experience?!