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  #1  
Old 11-07-2005, 10:50 AM
Mariaa Mariaa is offline
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It's open enrollment on hub's insurance which will be BCBS of Mass.

I now have WC to cover my low back with Lifetime Future Medical but they have decided not to allow the ADR surgery for me..

I have MediCare and AARP however, had to sign something w/medicare stating WC covers my low back and Medicare doesn't.

My question is if anyone has any knowledge re this.. would BCBS possibly cover a surgery that was denied by WC? It states on the information that is on the website that the insurance does not cover what WC does.

I'm going to call a rep. today and ask about this situation tho I'm not expecting to hear that anything related to WC is covered. Just wondering in the event WC won't cover a surgery recommended by 4 US spine surgeons now and 1 European surgeon that is one of the most reputable abroad...

Any replies are welcome and I'm just sort of not at my best at ferating out information right now as I'm still in a bit of shock/blue over this.. and open enrollment runs till Novem. 11th..
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  #2  
Old 11-07-2005, 12:43 PM
letteski letteski is offline
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Maria,

Has WC put anything in writing to you regarding their denial of benefits? If not I would make then put it in writing then you have something to fight. If it is all what they said it is only hear say and is not a true denial.

Getting on you hubbies insurance may be a good thing then you would have 3 insurances to cover the bills and one of them would should take the lead and the others will follow. Get all the plans and when I�m down I will help you read through them. There is some gargen that may be a loophole for you. I would love to help you with this. Something just doesn�t seem right to me.

Play hardball with them. Make them put everything in writing and don�t take NO for an
answer.
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  #3  
Old 11-07-2005, 02:06 PM
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Amen to Paulette. Get things in writing from W/C -

In my case, in this state - The State regulates the law that if it is a 'job related injury' and W/C is anywhere in the picture...Then my wife's Aetna CANNOT cover a thing.

When my W/C claim was giving me fits (still is, always has) I decided, after puking in withdrawals and not having a doc to monitor my spine....That I would attend another Pain Specialist on my wife's Aetna. NOT.....

The doctor's offices would not even take me in and see me, They said it is a conflict, WC vs. Aetna - job related - and that it would be illegal to even see me. (At that even, they would not and said NOT take my claim because It has been open for so long, 7 years, and they did not want to fight with WC.

I was not seen for 7 months but things may be alright temporarily here for me, I have the department ordering the self insured comapny to allow me to be seen....

What the department (WC) says and what the Self Insured says, MOST time are different things.
I document everything and have to trust my ATTY to straighten things out.
------------------------
There just might be a loophole in yours or the state of Mass. may be different than ours out West here? I do not know if I have helped, But if the results even said that I was ADR operable, I think that Aetna would cover it - But the State laws do not allow them to because it was job related. I could be WAY off and clear as mud, but only trying to help!
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  #4  
Old 11-07-2005, 07:36 PM
Mariaa Mariaa is offline
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RE my WC. UR has once already denied me this surgery so a decision has been rendered and handed down once already. The WC company tho at the time was willing to pay for the surgery. New heads are there now and a clean up of cases is going on so my case being and old one with Lifetime Future Medical (since '82) was one where the new Claims Head (not sure of exact title) said that this surgery was no longer being offered for me. However, she went on to say that if the request for multilevel ADR was put on the table again, UR would once again deny it and so that would be my final answer.

I don't have an attorney any longer. I have had Lifetime Future Medical Benefits since the early 80's. As long as WC isn't denying treatment all together, likely they aren't going to be found to be doing anything wrong.. there is the appeals process I can go thru when UR renders a denial of services..

Right now I'm not asking for anything as I need to get some documentation on something that I'll be asking if any of you can assist me with (in a seperate post).

Today I called Medicare and there'd be no problem w/having the BCBS insurance (of Mass. tho we live in CA. - it's just what the company is carrying) altho I was advised strongly to check out Medicare's new prescription drug coverage plans to make sure that the BCBS plan would be comparable or better.

Now on to BCBS. I have to call and ask to speak to a Benefit's Specialist. On the website for BCBS with the list of exclusions, WC related medical concerns is there.

Sometimes insurances do weird things tho and do cover what they say they don't or won't cover and vice versa so it's worth checking out ..I've found in the past information varies depending on whom you speak w/and often how well something is understood by the person giving the information (and then how much might actually be told to you or how much someone really wants to assist you)..and then some other turns of events...

One of the things in general I have concerns about is regarding the co pays, out of pocket deductibles and so forth as now that I've moved, I don't want to get into $ hassles w/spouse regarding this kind of thing..

If I do choose this coverage, and I ever want to go back on AARP (Medicare Supplement) I have to lose coverage from BCBS, it cannot be a voluntary choice to get back on it just in case there are some probs with how my spouse and I handle the policy coverage costs while we are living apart ...

sigh.. things like this make my stomach hurt..
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  #5  
Old 11-09-2005, 04:12 PM
luvmysibe luvmysibe is offline
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Hi Maria,
I have a bit more information regarding WC in CA and BCBS. I spoke with my surgeon's office manager and she said that in CA WC is only approving 2 level ADR for L4/L5 and L5/SI. My surgeon is actually performing this surgery next month for a WC patient. She also said BCBS of CA will not approve a 2 level ADR no matter what the medical finding and/or recommendations reveal. SO...the good news is that it is still possible to get approval, but check the underwriting insurer for your WC case. If your underwriter insurer is BCBS or CA good luck. If it is another insurance company you have a much better chance of approval. Oh, I also am unable to treat my WC injury and complications with my private insurance, strictly WC. Hope this helps!
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  #6  
Old 11-10-2005, 09:20 AM
Mariaa Mariaa is offline
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Crystal,
thank you.. what I need in writing is something about how the surgeon decides how many levels he can use the device for. Such as in Standard of Practice in the Community or guidelines by surgeons.

BCBS is what I picked in terms of medical care as I had called and found out they wouldn't do anything for my WC case...

thanks very much for your reply~
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