Appeal submitted

[jss]

Two weeks ago I finally got the expected formal denial from my insurance carrier for my ADR surgery. It took them six weeks to finally issue the denial. Anyway, I submitted my appeal yesterday; many dozens of pages.

Wish me luck!

[danzintommy]

How did you go with the appeal? And what grounds did they give for denial?
Cheers.

[jss]

You know Tommy, the first denial (the one mentioned in that post) was because they deemed the surgery was not "medically necessary". The appeal mentioned in that post was denied after about three months; this time claiming that multilevel ADR was experimental. I sent in another appeal in October (after many many hours of research). They denied again, this time claiming that it was company policy.

I've gone to my executive management at my employer who has contacted someone within BCBS-TX. That was ... maybe three weeks ago? I'm still waiting to hear something back.

Truth be known, I was fully expecting to receive no reimbursement when I had the surgery a year ago this Thursday. It is still infuriating.

[danzintommy]

We Aussies have a quaint expression for folks that behave like that "mongrels". There are so many precedents as well as scholarly research and published papers that health funds must be running out of ways to weasel out of this. After all, it promotes better health, isn't that what they want??
I know the US system will likely be different, but outside of the US in "English Law" systems like UK & Aust they have a body that oversees health funds etc - there;s usually an ombudsman. When I had the hassles with BUPA is trawled the UK Financial Ombudsman's website ( Financial Ombudsman Service) On that site you can find the appeals logic required as well as what health funds must/must not do. It's basically there to make sure people get a fair go. One point they do make on that website is about "experimental" techniques. They list there an organisation in UK that classifes whether something is experimental. And i just found the doc (http://www.nice.org.uk/nicemedia/liv...4935/44935.pdf).
Basically, disc replacement is classified the same as hip replacement!

Also- there are examples on the website (ombudsman) where claims are upheld against the health fund if they do not specifically exclude a procedure.

Hope this helps.