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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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Appeal using 'External Review' method
I received a denial on my initial request for reimbursement from Blue Cross World Wide. I had 2 level ADR surgery with Dr Zeegers in April.
There are two ways to appeal a health plan decision:
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Bad fall on A$$, Feb 2001 ice hockey Lami L4/L5 April 2001, L5/S1 Aug 2001 Severe dislocated coccyx (same fall) Un-diagnosed til 09. (Cannot sit) Low back pain mild until 2011 - pull started a generator from knees. rhizotomy Nov 2011 - zilch Facet joint inj. 18 mo. (no impact) Can only stand/walk for approx. 30 min 21 hrs/day in bed L3-5 Activ-Ls (April 2014) Dr Zeegers - walk every day, swim 3 x week. Pain free, no pain meds. Extremely pleased with my decision |
#2
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David vs Goliath
Just did a search on 'external review'. Not promising. Starting to feel like I am David and Blue Cross is GOLIATH.
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Bad fall on A$$, Feb 2001 ice hockey Lami L4/L5 April 2001, L5/S1 Aug 2001 Severe dislocated coccyx (same fall) Un-diagnosed til 09. (Cannot sit) Low back pain mild until 2011 - pull started a generator from knees. rhizotomy Nov 2011 - zilch Facet joint inj. 18 mo. (no impact) Can only stand/walk for approx. 30 min 21 hrs/day in bed L3-5 Activ-Ls (April 2014) Dr Zeegers - walk every day, swim 3 x week. Pain free, no pain meds. Extremely pleased with my decision |
#3
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Hen,
Second level internal is the first step. Most likely you won't win. You can however resubmit the claim after the second level internal. and or submit to the external appeal. Im going through this right now. PM me or email better. Don't want to post this here.
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Lumbar issues 18 yrs herniations lumbar L3-5 multiple Epis etc etc Annular tears L3-5 cauda equina Cervical herniation symptoms 2011 C5-7 M6C by Dr Clavel on June 5 2013 L3-5 M6L by Dr. Clavel on 12.18.13 Living life instead of living the condition |
#4
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Thanks Frank
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Bad fall on A$$, Feb 2001 ice hockey Lami L4/L5 April 2001, L5/S1 Aug 2001 Severe dislocated coccyx (same fall) Un-diagnosed til 09. (Cannot sit) Low back pain mild until 2011 - pull started a generator from knees. rhizotomy Nov 2011 - zilch Facet joint inj. 18 mo. (no impact) Can only stand/walk for approx. 30 min 21 hrs/day in bed L3-5 Activ-Ls (April 2014) Dr Zeegers - walk every day, swim 3 x week. Pain free, no pain meds. Extremely pleased with my decision |
#5
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Henry,
The only poster on this site I'm aware of that won a third party appeal for ADR has posted her story in this thread. Her appeal is different than yours in that 1)her surgery was domestic rather than international, and 2)she went through the appeals process before surgery, rather than afterwards as you and I did. She, gymnast1981, doesn't post here any longer but may respond to PM's. BTW: she almost four years post-surgery and is still doing very well. Wishing you the best of luck with those disingenuous son-of-a-guns at BCBS. Jeff
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C4/5 - ACDF in 2000 C5/6 - ACDF in 2002 C3/4 & C6/7 - M6 ADR, Nov 2009, Barcelona Conceded defeat to a manifestly disingenuous BCBS-TX in my quest for reimbursement, Jan 2011 |
#6
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Encouragement
Some words of encouragement-David won!
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Jen C3 Bulge C4 Bulge C5 ruptured C6 Bulge 7/2011 epidural that caused a "fragment to present itself" 10/2011 C5-C6 Foraminotomy & removal of fragment Positive for left-sided Hoffman's reflex Effacement of anterior spinal artery |
#7
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A second to Jens comment, won with a small stone I might add, but you know that Henry! Posted in my thread "cervical two level, Aetna" is my lengthy story so I'll spare you here but I just lost to an external appeal, but we talked about that so you know that too!
I am contemplating filing a suit. As that is the final step, not the external appeal like they want you to think. Everyone, under every plan has this option. I'm praying for guidance on it at this point. Not being hasty, but patience is a virtue, even when in pain. I will send my paperwork to you this week. Let's share share share info. No one has the time or energy to reinvent the wheel (the appeal, in this case) so let's all fight this fight together. I feel every win is a win for everyone. Even though my surgery is denied, there is still perseverance left in me to pave the path for others.
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2004 MRI -cervical bone spur causing pain 2011 MRI -5 bulging discs at C3-7: Recommended C5-6 and C6-7 for a two level fusion, I said no thanks. 2014 MRI -progressive compression C5-7. MRI 6/5/14- Ruptured L4-5, bulge at L2-3 and L5-S1 Dr recommends discectomy of L4-5 but won't do surgery until cervical is stable 8/2014- 8 months/3 rounds of appeals, Aetna denies 2 level cervical ADR 2 level ADR w/ mobi-c C5-7 Jan 7, 2015 |
#8
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Thanks Jen & Kel, I recently talked to a guy who had surgery with dr Zeegers (2 level lumbar, like me) back '04' with the Charite. He won with his 1st appeal. He sent me his letter - it was very concise and to the point. He says he felt that it was the particular company he worked for who he feels went to bat for him.
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Bad fall on A$$, Feb 2001 ice hockey Lami L4/L5 April 2001, L5/S1 Aug 2001 Severe dislocated coccyx (same fall) Un-diagnosed til 09. (Cannot sit) Low back pain mild until 2011 - pull started a generator from knees. rhizotomy Nov 2011 - zilch Facet joint inj. 18 mo. (no impact) Can only stand/walk for approx. 30 min 21 hrs/day in bed L3-5 Activ-Ls (April 2014) Dr Zeegers - walk every day, swim 3 x week. Pain free, no pain meds. Extremely pleased with my decision Last edited by henry4956; 08-26-2014 at 02:44 PM. |
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