News! Insurance Coverage for ADR

[Harrison]

Well, this is the first time I've ever seen an article that reported that a major carrier has covered the cost of ADR! An excerpt:

...Because the procedure is so new, it is not yet covered by many insurance companies, he said, but Thursday's operation was covered by Blue Cross and Blue Shield, and it will only be a matter of time before others follow...

The full doc is in the article library here. This is BIG news! I also have some news to report on the same subject but will hold it until next week.

[Mariaa]

Harrison,
thanks for posting this. There is a spine center nearby where I was living in Pinellas Co. Fla. that was advertising artificial disc replacement. This center wouldn't take my Ca. WC insurance to see me as a patient altho they didn't even do me the courtesy of saying so, tho kept refusing my calls.. they also had a report of a patient who was operated on the wrong extremity within the last few years so I wondered about this center. Tho apparently it does well and has a good following.
Am glad to see that the insurance coverage happened, as it should for the future! Thanks for posting this and will await what you're going to report next week!

[cavalier]

Thanks for posting this - now for BCBS to start paying for the P.D. I feel sicne the oepration is the same as prepping for a fusion - they can pay for all but the 3k my device cost - if they want to say exploratory & investigational - Jill
L4L5 ADR P.D> 7/6/04 Dr. B.

[Harrison]

Mariaa,

I am sorry about the runaround you got from that spine center. And �operated on the wrong extremity?� Yikes? I seem to recall a similar horror story from a patient earlier this year � good gosh.

Jill, for those folks not familiar with your �PD,� pls explain what that is�.thx

[wbaker68]

I will keep all informed on how quickly BCBS denies my 3 level prodisc replacement, I should be sending that information along to them shortly.

Haven't decided how much of a fight I will give them as I am just happy to be healthy again.

Bill

[cavalier]

Rich - the P.D. is short for my ADR Brand name - AKA Prodisc.

FYI - Bill I have been denied twice by BCBS for my ADR surgery - I am going to appeal it again for a 2nd appeal. I have heard of it takinf sometimes a 3rd so I figure what have I got to loose ? BCBS is paying for some folks ADR surgery so I feel it is the same surgery up to inserting the ADR as it is for a fusion - so if I can get them to pay for the surgery but not the disc - it will then have paid for the majority of my surgery -

Jill

[queenofhearts]

Let me know if anyone needs info for their appeal. Although my department has a "self-funded" medical policy, I still had to go through their appeal procedure, and won. They reimbursed me 90% of the total costs, minus airfare. I hit them with as many current reports and studies I could find, along with how much money I saved them (ADR in Europe vs. fusion in the United States), and how I was able to return to work with no restrictions.

The only argument they had was that the procedure was considered experimental and investigational. Now that the Charite has been mostly approved with the Prodisc to follow, I think a good argument can be made against the "e&i" clause most insurance companies have.

[mmglobal]

I'm going to be sending people here regarding insurance questions. It looks like this thread is a good place to consolidate info. So....

Kaiser and ADR

If there are other threads that should be listed here... or if there is a better place to consolidate... please let me know,

Mark

[Cindee]

My 2 level was approved with Blue Cross PPO. It paid 60% of the total bill. 80% of the hospital and everyone else. So I ws left with about 7000. TOTAL out of pocket. OH and I was on Cobra! Its ALL in the CODING process. It can be done, I think with most MDs, they just have to "finesse" the system.

[Harrison]

It�s taken a long time, but it looks like I am finally getting reimbursed from BCBS for my June ADR. What an exhausting journey - here are the hoops I jumped through during the past nine months:

1. Researched differences between ADR and fusion. Talked to patients, did online research, had appointments with doctors, discussed BCBS policy with their customer service reps. Determined that I would have to pay out of pocket for an �experimental� procedure.
2. Canceled fusion and scheduled ADR. Asked my doctor to write letter of medical necessity for my condition, which was submitted on my behalf to BCBS.
3. Filed initial appeal to BCBS (Appeals & Grievance Department) that was later rejected.
4. Performed more research on the appeals process, learned that there are additional �levels� of appeal process. Also learned that insurance companies work with third party arbitration firms for dispute settlement.
5. Opted to write and submit another appeal, which was rejected after 3 weeks.
6. Made many additional phone calls to BCBS; sent personal pleas to corporate executives involved in policymaking. All attempts appeared to be unsuccessful.
7. Made additional calls to the BCBS Appeals & Grievance Department to explore other options. Negotiated full coverage for ADR under the condition that the Charite� received final approval before year-end 2004.
8. Had ADR surgery on June 24th, 2004.
9. Final approval of the Depuy Charite� granted by FDA in October 2004.
10. Made many additional calls to BCBS to communicate final approval status of the Charite� (they apparently did not know).
11. Confirmed process for reimbursement with BCBS and doctor�s billing offices.
12. Received notification from doctor�s office of reimbursement credit on November 24th.
13. Received notification from BCBS indicating reimbursement charges for ADR procedure (20% of billed amount paid to the hospital!).
14. Will receive 100% reimbursement of my funds (less $500 for deductible) appr. December 14th.

I am sparing you a lot more details; there were many more steps involved. Alas, the end of a long journey�I hope this helps other people beat the system some people call unmanaged care.