Did your insurance pay? Let's help one another

[ans]

I have BC/BS of NY that authorized a two-level; also. a secondary BC of CA plan thru a university. Regan's office told me frankly despite this, I could get stuck with the bill - no guarantees. A bit unsettling. BC of CA's uitilzation review refused to answer directly if they have ever paid for an ADR before, re: precedent.

[biffnoble]

ADR procedures

There is also the issue of post-op care/follow-up.

INSURANCE QUESTIONS:
1) Who's on the hook for patient post-op ADR care?
2) How are USA versus non-USA procedures covered?
3) Non-USA & non-FDA approved?

If an FDA approved, insurance covered surgery is performed in the USA, then one would think that post-op care would be covered.

However:
If insurance covered surgery is performed out of the USA, and the procedure is non-FDA approved, e.g. multiple level cervical ADR, could the grounds that ADR is experimental, etc., be used as grounds for refusal of post-op coverage?

Or:
Self pay surgery is performed out of the USA, the procedure is non-FDA approved, e.g. multiple level cervical ADR. Could the grounds that ADR is experimental, etc., be used as grounds for refusal of post-op coverage?

Refusal of coverge would put the ADR patient on the line for 100% of, tens or even hundreds of thousands of dollars, of out of pocket costs.
A financial disaster for 99.9999% of patients!

Does this make �safe� surgeries (laminectomy, anterior fusion, etc.) any more palatable?

[ans]

Good points; rather sobering.

[Nancy from NC]

A couple more questions about insurance. I'm new here and still working on approval for a 2 level cervical ADR on top of a previous 2 level fusion. I already had a laminectomy on the area needing to readressed, and now have too much instability/lean, and then the previous fusion take me out of the criteria for ADR surgery in the US. So I am hoping someone in Germany will help me. Of course money is always an issue. So......
1. At what point do you try to get approval for a procedure overseas?
2. From what I am reading, am I correct in the fact that you can appeal your case before you have the surgery?
And My Main Question.......
3. Has anyone had any experience with complications after their procedure overseas and did their insurance cover the additional medical help/treatments that were directly related to those complications?

I appreciate any answers you might be able to provide. - Nancy

[casifer]

Hopefully some positive news for those waiting for insurance approval...

My ortho's office (Hamada, Los Angeles) just submitted the request to my insurance co (PHCS) 3 weeks ago to cover the Charlite ADR procedure at L5-S1. As an aside, this office also mentioned that not one of their requests for ADR coverage has been approved in the 5 months they've been submitting them.

30 minutes ago, I received the following vm from the office: "surprise, surprise, your insurance company approved payment for the procedure...".

No time-consuming appeal / denial / 2nd appeal, etc. process necessary. I feel very fortunate, after reading what most of the community has had to go through in getting insurance companies to pre-approve payment.

Hopefully as more and more of the insurance co's continue to approve the procedure, the rest will feel pressure to follow.

Good luck everyone.

[biffnoble]

Maybe the facts could be extracted from these posts and put in the FAQ's?

Each one of us is confronted with our own lousy scenario.

No ins.
Medi-cal
Medi-care
HMO
POS
PPO

Etc., etc..

There many other permutations to be considered.

Maybe when Mark gets the new 501(c)3 going this will be covered.

[Kim]

Congratulations on your approval!!!!! I am hoping to hear back from our HR dept with good news concerning my appeal on my surgery. I talked to the HR lady and she told me she should have an answer for me by the end of the week. Say a prayer its good news. Otherwise I start the ever dreaded appeals process. Our ins is self funded by the company my hubby works for so the company has more say so in the process. We are hoping they will take our side on this and tell the ins company to approve the surgery.
Kim

[Juli]

How do you know if your company is fully insured or self insured? Just call our HR I guess?

I called my insurance, UHC, to see what they had to say about coverage and the woman said she had nothing in her database regarding ADR and nothing against the CPT of 0091T which is what my research has shown to be the code for this surgery? She suggested I have my doctor submit a pre-authorization form and it will take about 30 days for them to respond. And I have yet to get a doctor to recommend it, so far they say fusion would be my next option, but as I can function day to day, they have not even recommended that although I have another appointment next month and I think that is what he is going to say as he said if the last round of PT and injections did not work that might be the "only" alternative as I have more than one bad level.

Anyway, it looks like it is the exception vice the rule for insurance to cover it at this point. I am probably going to have to come up with the money out of pocket and do the european thing, but am still researching and will be at the shindig May 1st.

Note NYC Jason's update about the moratorium in his new thread. Seems like it is roadblock after roadblock.


Juli
DDD L3-L4 on down since 1990

[ESL]

I have 3 codes on my pre-authorization:

63090 63091 and 22851

and you are right Juli.....your HR manager or benefits manager should be able to tell you whether your company (your hubby's company) is fully insured or self-insured (and if self-insured to what dollar limit).

[Juli]

Thanks ESL, does it give a description next to each code?

Juli
DDD L3-L4 on down since 1990