Did your insurance pay? Let's help one another

[biffnoble]

Hi Cavalib:

One alternative to hip bone is cadaver bone which is procured from a bone bank.

[Kim]

Wellllllll I heard from HR today and they said that the panel agreed with Great West to deny my coverage for ADR. She said of course I can appeal SIGH. OK so now I am going to get an appeal together. I need help from those of you who have done this.
What needs to be included in the packet? How much information did you send?
Is more better or do you think their eyes glaze over if you send too much?
Any help would be appreciated greatly!

I have also called TBI and asked that Dr Blumenthal be apprised of this and asked if there were any other options for me at this time. I cant but help believe that ADR will be approved in the near future and maybe just maybe they have something that could help me hold off til then.


Thanks
Kim

[ESL]

did they tell you the grounds for the denial...tha would be a good place to start.

[ESL]

kim

having gone thru what you just did last year, i might be able to help you.....leave me an email or phone number....I will reach out to you.

[Kim]

They stated as did the original letter from the insurance company that ADR was still considered investigational and experimental at this time according to their criteria that is why they denied it. I challenged it through HR since our ins is self funded and hoped they would over ride it but didnt. The underwriters and the panel with the company that my hubby works for agreed with Great West on this. They would not give me an answer when I questioned why it was still considered experimental when FDA approval had been granted in October. All I was told was I had the right to appeal and to send a letter to the Benefits Director. Hubby happens to be in San Antonio right now in a new training class and plans to phone the Benefits Director and see if he can talk to him in person while he is there and see if we can get anywhere with him.
Kim

[cavalib]

I know I said I wasn't going to appeal, but my whole family is upset with me because I won't "give it a try." So now I am going to appeal the denial.; Can anyone give me some info on what I need to do? What are the chances my ins. company is actually going to change their mind? I have gathered every medical record I have from every doctor I have seen for my back over the last 7 years. Is that helpful?

[gary]

2 level prodisc under trials, santa monica ca....under PacificCare PPO.
10-20% my share, still huge amount compared to
what you are prepared for, along with increased
premiums, i paid more than some going to germany
or other foreign lands

[paulam310]

I received a 3 level adr 12-7-04, Blue Cross PPO approved me without question. I didn't realize that insurance companies were not approving; I feel like it's awful not to approve such surgeries. Keep fighting 'till you get what you need!

[Rein]

Originally posted by paulam310:
[qb] I received a 3 level adr 12-7-04, Blue Cross PPO approved me without question. I didn't realize that insurance companies were not approving; I feel like it's awful not to approve such surgeries. Keep fighting 'till you get what you need! [/qb]

Paulam310: For a lot of this, the issue of insurance is the prime reason we are not on the road to recovery. It would help a lot for you to post more details of your case here in this thread, even though you have posted elsewhere on a couple of the details.

Speaking of those details, you mention elsewhere that your surgeon was Dr. Lauryssen and you received the ProDisc. The fact that any insurance, and BCBS in particular, paid for this at this time (without appeal!!!) is astounding, given the fact that the ProDisc has not been FDA approved yet. If I'm not wrong, the ProDisc initial study was closed last October or thereabouts, so I'm assuming your procedure was part of the continuing access availability that has been allowed, and so the discs themselves were supplied free by Synthes. This still leaves the rest of the costs of surgery, hospitalization, etc.. Is it possible that you misspoke, and your discs are Charite? This would explain a lot.

Also, it would help to know if your insurance group is self-insured, to what extent, and how many members it has. Also, for those of us who do not know your doctor (or didn't see your other posts), it would help to mention the facility (and possibly other doctors) with which he is associated.

[Eddie_G]

Has anyone here had any dealings with Liberty Mutual (specifically Workers Comp)? Do they seem to manifest any socially redeeming characteristics? Or should I prepare for a fight?

Don't we have enough problems without having to worry about OUR OWN insurance companies screwing us over, making us jump through hoops ect...?