Did your insurance pay? Let's help one another

[paulam310]

Rein, let me try and clarify my surgeries and insurance. I received a diskectomy from Dr. Lauryssen 11-03 at C6. Then I received a 3 level prodisc from Dr. Delamarter 12-04 at C4-7. PPO stands for participating provider organization. I bought the insurance myself as a self-employed person. My first surgery was at Cedars and the second one was at St. John's, both in L.A. which is where I live. Since the prodisc is still in a trial all the discs were free, I believe that is the rule until the FDA approves the disc. Hope that answers all your questions.

[chuxk79]

KAISER a Chance
I called kaiser Customer Care about my 3 prodisc
surgery in Jan 05 and they sent me an emergency
form to fill out which I did and I provided some info on my surgery with Dr.Bertagnoli.
I thought I would get an immediate turn down
answer but they sent me a letter wanting copies
of my airline tickets,Doctors Report, and proof of payments.
I'm preparing to take my time and write a outlined letter regarding my surgery but I personally think it will all boil down to how the word "Emergency" is defined.
Kaisers handbook says an emergency medical condition is a medical or physchiatric condition
that manifests itself by accute symptoms of sufficient severity ( including severe pain)such
that you could reasonably expect the absence of
immediate medical attention to result in serious jeopardy to your health, serious impairment to your bodily functions, or serious dysfunction of
any bodily organ or part. (whew thats the most I ever typed) I personally think that being in years of pain and depression and once in a while
feeling suicidal from 24 hour a day pain should surelly qualify. I'LL KEEP YOU ALL POSTED
HOPEFULLY I WILL COLLECT SOME OF MY $46,000.00
Chuck Dobovsky

[paulam310]

Mark, you are correct. I received a 3 level cervical prodisc 12-04. I was the third person in the US to receive it.

[Mrowe]

My husband has DDD L5-S1. He is 38 years old and cannot do anything because of his pain. He is on heavy medication. It has been years since he has been able to function normally. Our insurance company, Humana, recently turned him down for ADR. They said it was still experimental in nature. Anyone have any suggestions for us in the appeal?

[NCFUSED]

Mrowe,
I am exactly the same age as your husband and same condition including heavy meds. I lost all of my appeals (3) w/ UHC and my employers benefits commitee. Your best bet would be to find out if your insurance is self funded by your employer or fully funded by the Ins. Company. If the later, you can appeal to the state, if self funded, his employer has final say, as did mine.

[Mrowe]

I believe they are self funded. He actually is retired - disability due to his back. It began with a back injury and now we also have a worker's comp lawsuit going. They paid for 2 years worth of medicine and doctor visits, then they decided they had paid "enough". I highly doubt whether the company would ok his surgery then, considering the lawsuit and all. Did you end up having fusion? I think that will be the doctor's suggestion. The problem is that his 3 bottom disks are all bad, just L5-S1 is the worst. So he may have to have 3 fused.

[NCFUSED]

I have a real bad DDD at l5-s1 and slight DD at L4-L5. Ive opted for fusion at L5-S1 and going to wait out the other. I am hoping ADR will be more widely "covered" by insurance at the point that I will need it.
Im working on scheduling fusion surgery right now...

[Mrowe]

Thank you for your help. My husband just heard back from the doctor and he will also be going for fusion. The doctor said we could appeal, but it would take 3 months and most likely get the same answer. Good luck to you!

[NCFUSED]

Best of Luck to your husband and yourself also.... As I know you are suffering along with him (I know my wife puts up with a lot lately)...
People tend to forget that our spouse's suffer along with us....

[Rein]

Originally posted by paulam310: (and edited by Rein)
[qb]I received a 3 level cervical ProDisc from Dr. Delamarter 12-04 at C4-7. I was the third person in the US to receive it. I bought the insurance (BCBS PPO) myself as a self-employed person. My first surgery was at St. John's in L.A. where I live. Since the ProDisc is still in a trial all the discs were free.g [/qb]

I subsequently emailed Paula about some details of her post and she was gracious enough to allow me to post her reply:

�05/05/01
Rein, I wanted to add that insurance, after the deductible and co-pays were met, paid all hospital charges. My doctor is out of network so of course I had to pay him a higher fee, that would have happened no matter what kind of surgery I had. So insurance paid my doctor their blue cross ppo rate, then I was responsible for anything over that.�

As a matter of fact, unless BCBS PPO plan for California is different than Massachusetts (which is certainly very possible), for a member to use out-of-network providers first the deductible ($250/member/year) must be paid, then the co-pay, which equals 20% of the allowed charges up to $1000 per member per calendar year. This means the total should have come to $1250, if my math is correct.

What completely baffles me is why Paula�s surgery was paid for by BCBS if her procedure is still in FDA testing (which the ProDisc-C still is), whether it had anything to do with the fact that she is totally self-insured or whether Dr. Delamarter has some clout with the local BCBS providers due to their experiences with previous ProDisc cases. Why in the world would BCBS pay (without even escalating to the appeals process, yet!) if they�re still denying some people the Charite, which *is* FDA approved?!! This is crazy!

Paula, I�m still extremely happy for you, that you were able to obtain this procedure with no hassles whatsoever, and hope and pray that you develop no complications. The fact that most of the rest of us are struggling against the odds for the same thing should in no way diminish your feeling of success. You go, girl!

If anyone has any insight into the questions I�ve posed, please, PLEASE!, either post some answers or email me direct! Thanks.