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  #1  
Old 03-20-2006, 05:29 PM
djscal djscal is offline
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Hi,

You may recall from prior posts that Regence BCBS had paid for my hospital charges for ADR (without any appeal). 2 months ago they denied the Orthopedic and Vascular surgeons' bills citing experimental and investigational. I had pre-negotiated with these 2 docs in case the insurance gave me trouble. So in the event that insurance company wouldn't pay them a dime, I'd be out less than 10k. I sort of internalized that I would have to pay the bills but I appealed anyway. I just was notified that I won the appeal (sort of) and that insurance company agreed to pay for the orthopedic surgeons bill (the bulk of it) but denied the vascular surgeons bill as investigational/experimental. I am really confused because both surgeons participated in the exact same surgery at the same time - why would they pay for one but not the other? Very strange! I will appeal the denial for the vascular surgeon's bill. Crazy insurance companies!

Moral of the story - TAKE THE TIME TO APPEAL!!! You never know what will happen!

Dan

p.s. I wrote the crappiest appeal letter and provided zero supporting documentation, because I figured the 1st level appeal would be a formality anyway... Even stranger huh? (shrug)
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Age 34
DDD L5-S1, bulge and Grade V annular tear.
SED 2/15/05 - no luck
Charite @ L5-S1 8/2/05 with Dr. Regan
Struggling with facet joint pain.
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  #2  
Old 03-20-2006, 07:41 PM
Mariaa Mariaa is offline
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Dan,
That does sound odd, especially since the vascular surgeon was doing what was necessary tho not the one to place the implants so it would seem that his part of the bill should have been paid and the ortho's not.. (if going on premise investigational and etc)...altho, I've forgotten if you had this surgery before it Charite was FDA approved because if so .. then why would anyone's participation in the surgery be investigational etc?

Yes, take time to appeal.. will likely end up going this route when the next surgery that is sent to UR for request to authorization is turned down..

Glad to hear that you won your appeal~ I can't imagine you writing a crappy letter.. tho strange that you didn't need any supporting documentation...
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  #3  
Old 03-20-2006, 09:47 PM
letteski letteski is offline
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Way to go Dan....Give it to them where it hurt....again and again. If you write a good letter they may start paying you.

That is the craziest thing I have heard of who is suppose to open you up and put you back together again. They do anterior approaches for fusion is that considered investigational/experimental too.

Geeeeeeeeees do they know what their doing/

BTW did they pay for the disc?
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Paulette
ProDisc L5-S1 W/Dr Delamarter Aug 23, 2005
L5-S1 DDD Diagnosis 12/04
T-12 Compression Fracture 10/04
C-7 Spines Process Fracture 5/99
http://prodisc2.blogspot.com/
You are my Rock God in you I can do anything
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  #4  
Old 03-21-2006, 12:32 AM
ans ans is offline
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That is incredible. I have Empire BCBS of NY and I was informed by Regan's office and someone else that they will flatly deny payment. Maybe things were different when you had surgery and they changed policies. In any case, congratulations!

Allan
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Severe, extensive DDD, considered inoperable by Dr. Regan, Lauressen, & some guy at UCLA. Severe foraminal stenosis (guess they can't operate!) and some spinal cord compression that Lauryssen would fix if gets outta hand.
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  #5  
Old 03-21-2006, 12:28 PM
djscal djscal is offline
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Maria,

I had the surgery after FDA approval.

Paulette,

I wasn't charged for the disc; it was lumped into Regan's bill.

Allen,

I was told by both Regan's office and Mednet (his billing company) that they wouldn't pay for ANYTHING. They were both wrong.

Dan

Here is my appeal letter (I borrowed a lot from JimM2's appeal letter):

Dan's Appeal Letter
__________________
Age 34
DDD L5-S1, bulge and Grade V annular tear.
SED 2/15/05 - no luck
Charite @ L5-S1 8/2/05 with Dr. Regan
Struggling with facet joint pain.
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  #6  
Old 03-21-2006, 03:37 PM
ans ans is offline
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Dear Dan,

Thank you for linking this great letter.

I was told by George Tanner who's wife has back problems (he has inside info. to BCBS of NY) that they will deny now - vs. before. Maybe this is specific to NY though.

At any rate, you got paid in your bittersweet victory that I'm sure one day you'll be fixed again.

Allan
__________________
Severe, extensive DDD, considered inoperable by Dr. Regan, Lauressen, & some guy at UCLA. Severe foraminal stenosis (guess they can't operate!) and some spinal cord compression that Lauryssen would fix if gets outta hand.
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  #7  
Old 03-21-2006, 06:07 PM
Mariaa Mariaa is offline
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Wow, that was short and to the point, esp. re what Dr.Whitworth said.. which I remembered him pretty much stating the same thing back when I was questioning whether or not to have a 3 level global fusion back in '98!

His reply stuck with and served as one of main influences in my life back then re to fuse or not to fuse..
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