My process so far!

[Nichole]

Hi everyone,

It was brought to my attention that I should let you all know what I have gone through so far. I am sure most of you read my earlier post about my insurance denying me for the ADR. I am now in the process of my second level appeal. This is what I have been working on the last couple of weeks.

I wrote a letter to my insurance company requesting an "in person" appeal and faxed that over to them yesterday. In the meantime I have also been doing alot of reaserch on what information I can bring to the appeal. Who I can bring etc. My doctor and I are working very closely together on this appeal. He will be attending the "in person" appeal as well as a representative from the manufacturer of the Charite. Which is really exciting.

I have contacted my local insurance commissioners office and they have put me in contact with SHEBA (Statewide Health Insurance Benefits Advisors). I spoke with a gentleman today from that office and he told me the following information. If I can get in writing a letter from Medicare stating that this is covered benefit this will be another plus in my corner for the appeal. I will need to bring that documentation to the appeal and state that "Medicare is seeing this surgery as reasonable and customary, therefore it is a customary treatment for my diagnosis". Usually when Medicare covers a procedure it's not long before the other insurance companies follow suit. I am hoping that the Artificial Disc follows as the others have. I am also trying to get as much information as possible to bring to this appeal. I would like to talk to as many people as I can who have had success on their appeal and find out what verbage was used, what codes and etc. to bring to my appeal.

I was helped by Richard in some questions to ask Regence and my local insurace commissioner prior to my "in person" appeal. They are as follows: Who will be present from the insurance, What are their roles, What kinds of questions will be asked, and Who can I bring and what can I bring?

I just spoke with my insurance company and the following people will be present for my appeal:
Registerd Nurse w/panel of representatives who are as follows: 1 company representative, 1 appeal counselor, 1 administrative representative who is a member service specalist with contracting, 1 enrollment and claims specialist, and one medical director. Phew, thats alot of people from their side. A little overwhelmed by that. Yikes, I am feeling a little scared now about this appeal.

Anyway, I will continue to post my process as I go. Thank you again to all of you for your support, suggestions and prayers as I walk this journey.

Nichole

[Leanne]

I am so sorry to hear about your insurance battle, but do not lose hope. I just "beat" Anthem in Kentucky. An independent review panel decided in my favor and now they have to cover my ADR, scheduled for 3/14.
I am an attorney, although I'm not licensed in your state so this is not legal advice per se. However, your case against them is in contract. Your policy is a contract. You fulfilled your duties by paying premiums, submitting claims properly, cooperating, etc. The company must fulfill its duties. However, you need to read your policy to determine exact what those duties are. Most policies are written in the affirmative -- "We will pay ..." -- with exceptions. I assume you are being denied based upon the "experimental/investigative" treatment exception. That exception is probably a defined term in the policy and you need to see whether your claim meets their definition. If not, and if there are no other applicable exceptions, your company must pay. "Will" is manadatory.
You need to request all documents and other data used in your appeal from the insurer. Find out exactly why you were denied and if that is correct. It sounds as if you have the burden of proof at this hearing, so you need to present evidence as to why the insurer is in breach of the contract (because your claim meets the definition of what is covered by the policy).
I'm emailing you my final submission to the external review board as well as their decision letter to me. I would submit your argument in writing like this prior to any hearing because it's hard to get everything in at hearing. I'd be happy to email this to anyone else in need of help. If someone has a contact at Dupuy Spine, I'd be happy to provide anything they want. Please feel free to contact me directly about this. I'm happy to help.

[Harrison]

thx Leanne, I believe many people will benefit from your experience! I'll send you contact info for the Depuy folks.

[Nichole]

Leanne,

Wow, thank you for all of that information. If you could email me with your contact information I would love to chat with you. I should hear with 72 hours when my in person appeal is going to be. I definately want to go prepared. I will go through my benefit booklet tonight and see what I can find.

Thank you again.

Nichole

[bmills]

Leanne, could I also have that information. My email is bmills@adams50.org. Sorry but I could not find your email address in your profile.

Thank you!

Brady

[mwmc76]

Leanne, if you don't mind I would also like a copy of any insurance information you could provide in winning an appeal. Email: Mwmc76@aol.com Thanks, Mark

[Lori]

Congratulations on your approval. I am having the same problems with my insurance, Blue Cross/Blue Shield of Tennessee. I am a two level candidate and have begun the hurdles with the insurance people and the search for a competent surgeon. I would like to get your final submission and the review board's decision via e-mail. I'm sure I could use the information to fight my battle.
Any help on a possible surgeon in Tennessee would be appreciated. I live in Chatanooga.

[mwmc76]

Lori, I sent you an e-mail please look for it. I too am from Chattanooga and would like to share with you what I know. I am dealing with BCBS of Tennessee also and can help with some info on some U.S. surgeons.

Mark(Tennessee)

[Nichole]

Lori, I will email you on Sunday all the information that I have as well as a copy of my appeal.

Nichole

[Patrick]

Originally posted by Leanne:
[qb] I am so sorry to hear about your insurance battle, but do not lose hope. I just "beat" Anthem in Kentucky. An independent review panel decided in my favor and now they have to cover my ADR, scheduled for 3/14.
I am an attorney, although I'm not licensed in your state so this is not legal advice per se. However, your case against them is in contract. Your policy is a contract. You fulfilled your duties by paying premiums, submitting claims properly, cooperating, etc. The company must fulfill its duties. However, you need to read your policy to determine exact what those duties are. Most policies are written in the affirmative -- "We will pay ..." -- with exceptions. I assume you are being denied based upon the "experimental/investigative" treatment exception. That exception is probably a defined term in the policy and you need to see whether your claim meets their definition. If not, and if there are no other applicable exceptions, your company must pay. "Will" is manadatory.
You need to request all documents and other data used in your appeal from the insurer. Find out exactly why you were denied and if that is correct. It sounds as if you have the burden of proof at this hearing, so you need to present evidence as to why the insurer is in breach of the contract (because your claim meets the definition of what is covered by the policy).
I'm emailing you my final submission to the external review board as well as their decision letter to me. I would submit your argument in writing like this prior to any hearing because it's hard to get everything in at hearing. I'd be happy to email this to anyone else in need of help. If someone has a contact at Dupuy Spine, I'd be happy to provide anything they want. Please feel free to contact me directly about this. I'm happy to help. [/qb]

Leanne,

I would also really appreciate an email of your final submissions. Thank you much