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Insurance Hell All insurance-related matters are here: Medicare, worker's compensation, appeals, denials, insights, wins, losses. PRICING is here too. Note: This forum has posts from 2006 forward. Older ones are in the Big File. |
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#1
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just received an email from Laurie todd about a successful ADR reversal.
Quote:
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*********************** 1/2006 DDD L5/S1 Prodisc St. Mary's 12/2006 not diagnosed properly pre-op and now have DDD L4/L5, facet calcification L5-S1/L4-L5, mild scoliosis and left knee pain. DDD: C3 through C6 |
#2
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I am going to try fighting Blue Shield using your outline - thanks so much for the advice, very well written appeal and kindness in sharing it with us! So glad you got reimbursed. I was turned down several times too, but I wasn't even allowed to see an ADR doc!
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Lisa Back/neck pain with chiropractic treatment 3 x week in 1973 (age 13) for 1 year and pain since then due to falling off horses headaches since age 17 Onset of severe fibromyalgia in 6/95, undiagnosed for 2 years while lived in UK About 1998 o |
#3
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Hi Everyone,
My husband and I have used this appeal outline. Verdict is still out. My husband will be submitting the appeal tomorrow to our insurance and the president of his company. This is our second appeal. I bought Laurie Todd's book and it is worth every penny. Regardless of the outcome it is a real eye opener. |
#4
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FYI
that is not my outline. that is what laurie sent out on her email list. feel free to use it. Keep us posted if it works for you.
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*********************** 1/2006 DDD L5/S1 Prodisc St. Mary's 12/2006 not diagnosed properly pre-op and now have DDD L4/L5, facet calcification L5-S1/L4-L5, mild scoliosis and left knee pain. DDD: C3 through C6 |
#5
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Actually, Laurie sent me this appeal after I purchased the book a few weeks ago. She has a wealth of information and my husband and I have exchanged several e-mails with her since I began the insurance process. I am looking forward to a response which I will have in 15 days. That being said, since my husband's company is self insured I am not sure who will make the final decision. Time will tell.
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#6
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Indeed, good news from Laurie Todd and her ADR client! Great work!
That being said, I deleted the actual (edited for template) appeal, written by Laurie and her client, from Zorro's message. I don't care to help the people working AGAINST patients by giving them helpful insights into our battles against them! If you need it, simply email me - or Zorro.
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"Harrison" - info (at) adrsupport.org Fell on my ***winter 2003, Canceled fusion April 6 2004 Reborn June 25th, 2004, L5-S1 ADR Charite in Boston Founder & moderator of ADRSupport - 2004 Founder Arthroplasty Patient Foundation a 501(c)(3) - 2006 Creator & producer, Why Am I Still Sick? - 2012 Donate www.arthropatient.org/about/donate |
#7
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Harrison,
Good idea on the removing the appeal. I say buy the book for $14.95! It is well worth the money. Laurie Todd is a huge help if you have any questions. |
#8
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I too have been in touch with Laurie. She sent me the outline and at first I didn't think I could use it in my case. But then I printed it out and was able to edit, add, delete various parts of the appeal and then in the end I was able to modify it enough to pertain to my case. I sent mine out on the 25th of this month so, we will see. My insurance company Motion Picture Industry, Blue Shield, Ca. Department of insurance should all have it by Monday the latest. Hope it works for me. The insurance company denied me 3 times and most likely thought they were done with me back in April. They stated the only other thing I could do is sue them in federal court. We will see....
Abbe
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Water ski accident 86' Chiropractic& PT Pain meds Discectomy Laminectomy L5 S1 Partially sacralized 97' epidural injections L3 L4 ruptured and torn L4 L5 Almost no disk height left along with osteophytes Left leg pain and tingling going down back of leg into heel & foot 3 appeals with BCBS no success Lost insurance. Kaiser Permanente L3-L4, L4-L5 Prodisc 9/18/09 C5-6 & C6-7 ruptured and looking at hybrid surgery fusion & Prestige ADR |
#9
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Hi! I am brand new to this community so I am not sure whether I am requesting this info properly or not, but could the author of the message Re: victorious appeal against BC/BS e mail me the strategy used? I don't seem to have a chance against my BC/BS insurer. I am one of the few who needs both ALIF at L5-s1 & ADR at L4-L5. Have been in pain for two years and I really need surgery!!! Any advice would be appreciated. Please send to l5-s1@hotmail.com. Thank you kindly!!!!
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#10
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TriWest ADR Denial
Hello Everyone I am new to this Forum and was wondering if anyone has been approved for a cervical ADR... I received my denial yesterday and sent thid email below as a request for medical review reconsideration..
26 July 2010 TriWest Health Care Alliance Reconsideration Department PO BOX 86508 Phoenix, AZ 85080 To Whom it May Concern: I am writing to request a formal appeal of the rejected proposed treatment, cervical disc arthroplasty, for the following diagnosis: * Cervical Disc Degeneration * Chronic pain to neck and to right scapular region * Chronic Muscle spasms to neck and to right scapular region * Nerve Palsy to right upper shoulder and arm * Cervical Radiculopathy * Spondyloarthropaty of cervical spine * Loss of normal lordotic curvatrure of the cervical spine * Mild disc desiccation * Headaches All of my above listed medical diagnosis are documented with associated numerous tests that I have been put through since approximately 2007. Sadly, I have attempted and failed numerous rounds of conservative treatment only to live in constant pain and always scared and guarded to not have an acute spasm which feels like I have been struck by lightning in the back of my neck. This is also affecting my career because of the numerous medications and vigorous expectations that are demanded by my profession. I can no longer work as an emergency-trauma Registered Nurse Specialist. I am currently in graduate school for Acute Care Nurse Practitioner but with my chronic neck problems this could shatter my dream, as well. At my age a fusion would literally put me on the "bench" forever. I have three young children that I would love to conquer adventures with. With a fusion there would be serious limitations. I have tried soft c-collars, trigger point injections, Chinese acupressure, Chinese acupuncture, cupping, tens-unit, moist heat, cold therapy, cervical pillows, tempur-pedic bed, physical therapy, professional massage, chiropractic adjustments, freezing and stretching with ethyl chloride, prednisone, NSAIDS, narcotics, lyrica, neurontin, muscle relaxers, the Felix trigger point board, cervical epidural injections, facet injections and ultra sound therapy. I have literally spent thousands of dollars and have exhausted every possible remedy to relieve this horrible condition so that I can start living my life like I used to. Dr. Briggs, my neurosurgeon from the Springfield Neurological and Spine Institute, Dr. M. Akhtar Choudhary (my neurologist) and I have all agreed that the cervical disc arthroplasty is the most appropriate treatment for my condition and that I DO meet criteria for disc arthroplasty and should undergo this surgical procedure. Please find the attached documentation that may be helpful in your reconsideration of the pre-authorization claim for benefits and payments in which Tri-Care does cover for all Active Duty Soldiers, but is sadly denying their dependants of this medical necessity: * A copy of "not approved" letter * Medical Justifications for cervical disc arthroplasty * Clinical literature on disc arthroplasty * A letter from my doctor * Cost benefit analysis reports * FDA approval letter for the prestige ADR Thank you for your consideration of this much needed coverage . If there are any questions please contact me at 573-847-8246 Angela M. Barco RN, BSN |
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Tags |
adr insurance appeal, artificial disc replacement appeal, insurance appeal, spinal arthroplasty coverage |
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