insur. co won't pay for ADR & I'm running out of time

[Karen]

Hi, I'm new...I'm also desperate and panicky. My insurance company (Cigna PPO) denied coverage for an ADR because they consider it experimental/unproven. After looking at other postings, I've concluded that the appeal process is likely to be very slow - but I'm up against a wall and can't wait long - early August at the latest. If my chances of succeeding by then are slim, I'll have to try to get an ADR some other way. Can anyone give me a "guesstimate" on how much time my appeal will take?


I'm in a rush mainly for financial reasons. I have to support myself and 2 kids (single mom, no child support). After missing nearly 2 years of work due to back pain (a failed laminectomy at L5-S1 left me w/ severe pain when sitting/standing), my employer laid me off just before Christmas '04. Right now, I'm paying thru the nose for COBRA coverage, my state disability benefits have been exhausted, and my SSD claim is still pending (even if I'm approved, my award will be less per month than my rent).


Meanwhile, to keep from losing my mind while waiting for surgery, I continued going to school. After driving to school, sitting or standing in class was impossible, so I brought a thick yoga mat with me, spending my first semester of law school lying on the floor in constant pain. (Fortunately, UCLA has phenomenally wonderful support for disabled students.) It got so bad that I took this semester off to have the surgery. Anyway, I really need to go back to school in August because I need my student loan $ for living expenses and I need the dirt cheap health insurance (Blue Cross - no exclusion for preexisting conditions) that's included in my tuition. Here's another question: does anyone know whether Blue Cross (California) is covering ADR?

If I can't get it covered by insurance, my brother has promised to refinance his house so he can lend me the $ for the ADR. I'd hate to do that to him with no way of knowing whether I'll ever be able to repay him. If I do go this route, am I correct in thinking that it would be at least $10K cheaper to do it in Germany? If so, does anybody know how long I could expect to wait for a surgery date? How about suggestions as to which clinic?

[ans]

Hi Karen. I'm sorry you're going throgh this.

I'm a UC student and I hear conflicting reports that BC w/not pay to that they will pay. I was told to call the Utilization Review robots but they wont' reveal anything. I'm sure others here w/provide help.

[Justin]

Karen,

I am sorry to hear about your situation. My in-person appeal with BCBS was one month after my denial letter. I think it was only this fast because I became a real pain in the butt if you get my drift. Too bad they already had their mind made up before I walked in the door for my appeal.

Anyway, I think there are a few people on this forum that have had BCBS pay a percentage of their surgery. Hopefully they can chime in.

It is cheaper to do in Germany/overseas. However, the dollar is very low against the euro right now (which will have a significant impact on the final amount). My first email was with Dr. Bertagnoli during the first week of October 2003 and I had surgery on November 15th, 2003. He (and many other surgeons overseas) is pretty busy these days--the man is a machine though and requires no sleep or rest. It is quite amazing how he is in a different country almost everyday of the week.

Please do not hesitate to send my a private message or email.

I wish you the best,

Justin

[NCFUSED]

For State help with appeals in California check out the following:

http://www.kff.org/consumerguide/CA.cfm

My 1st Denial took 3 months to get from UHC,
My 2nd Appeal denial took 30 days.
Now Im appealing to my Company's Benefits Committee since we are self insured.

Good Luck in Your Battle....If I can be of any help please let me know.

[Nichole]

Karen,

First of all let me send you my sincere empathy. You have come to the right place to get your questions answered.

I started my appeal process in January and am now starting my 4th and last level appeal. The entire process will be complete by the end of April. I had to start with a pre-auth (denied), then 1st level (denied), then 2nd level (denied) then 3rd(just denied), now 4th.

Hope that helps. You are also welcome to private message me with any other quesitons.

Best of luck to you.

[casifer]

My surgeon's office (in CA) submitted my initial request for ADR coverage last week. I was told by his office that they have been submitting ADR requests to various insurance co's for 5 months, and not one has yet been approved.

It sounds like many of us are going through this submission-denial-appeal-denial... process. I think we all believe at some point the insurance co's will agree to cover the ADR procedure (last week's Aetna clinical policy was a very positive step). However, I'm wondering if down the road when the insurance companies eventually agree to cover ADR, will they also agree to retroactively reimburse the patients whose appeals they previously denied in early 2005?

Since I probably wouldn't move forward with the procedure if I thought I would end up paying 100%, I'm debating whether to hold off until the insurance co's are paying for the procedure, or pay for it myself now and request reimbursement down the road.

Anyone had experience with this?

Thanks.

[insurance problems]

In the same situation advocating for a family member. The state board denied it and we are trying to reopen the case. I am curious if anybody has any experience or is knowledgable in predicting what the efficaciousness of having groups of patients lobby a congressman/senator/state rep collectively?

Thanks

[Karen]

Thanks so much to everyone who took the time to reply. Although my situation hasn't changed in the few days since I first posted, somehow my anxiety level has dropped because I feel that I'm not so alone - I'm now part of a group who understands.

[biffnoble]

Karen: don't get surgery out of network w/out first confirming post op care will provided by your carrier. Otherwise you could be SOL!

[ans]

Excellent advice Cervie!

I'm glad you feel less alone.