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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  
Old 09-16-2018, 12:06 PM
GravyBaby's Avatar
GravyBaby GravyBaby is offline
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Join Date: Mar 2018
Posts: 132
Default Florida Blue (BCBS Florida) Approval!

Hi all,

I was shocked to find out last week that BCBS of Flordia, known locally as Florida Blue, approved my lumbar disc replacement surgery procedure (L5-S1) in full (minus my deductable) with Dr. Rolando Garcia of the Orthopedic Care Center of Aventura Hospital in Aventura, Florida, after a short (5 day) medical review.

Dr. Garcia informed me during our second meeting, around the end of August of this year, that he heard Florida Blue was on the verge of adopting lumbar ADR into their standard procedure approval. On researching on my own, I found that a reported 62% of nationwide insurance companies are now covering the procedure, with more joining the ranks by the end of the year.

I crossed my fingers and hoped and prayed and really lucked out. It took one week (5 business days) to get the approval. Even more lucky was that we did not have to submit an appeal. I thank Dr. Garcia's staff for preparing the submission to our insurance with great expertise.

It is possible that my condition had something to do with the quick approval. I have retrolisthesis, a form of spondylolisthesis, which has progressively incapacitated me over the past year. In addition, the new strict opiod laws forced me into the emergency room three times the week prior to our insurance submission. Those factors may or may not have played a role in the quick approval.

I would highly recommend Dr. Garcia for anyone in the US looking to get their ADR surgery approved through insurance. His staff is ready to help and he will answer any questions you may have.

A little info about Dr. Garcia: He was co-developer in the latest FDA-approved artificial lumbar disc, the Activ-L. He was part in the FDA trials for the Activ-L. He has performed hundreds of successful ADR surgeries with the charité, prodisc and Activ-L devices over the past 18 years.

Good luck to everyone in their quest for insurance coverage!
__________________
2001 - Pulled off monkey bars, landed directly on coccyx.
2006 - Sports injury that made it worse.
2016 - Multiple instances of paralyzing low-back pain.
2017 - Blew out my back on leg-press. MRI showed L5-S-1 disc herniation and grade 1 retrolisthesis.
2018 - Successful ADR surgery with Dr. Rolando Garcia using the Activ-L implant.
2019 - In physical therapy for burning in feet, L4-L5 diffuse disc bulge and SI joint pain.
2020 - Getting better with one-on-one PT.

30 - Male - American
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  #2  
Old 10-26-2018, 07:46 PM
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GravyBaby GravyBaby is offline
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Join Date: Mar 2018
Posts: 132
Default

BIG UPDATE!

I found out today that my insurance company REVERSED their decision on my surgery and reversed their payments to my physicians and hospital for my surgery weeks after I had it done. I only found out because I went to refill my prescription and they asked me to pay. I had already hit my out of pocket maximum and deductible with the surgery co-pay and was enjoying not having to pay any more for my medical care.

I come to find out that my co-pay for the surgery was removed from my insurance account entirely. I am now having to pay for doctors visits and medication out of pocket even though I already paid a bundle to my doctors office for the procedure. Currently in the process of working this out with my insurance company and doctors office.
__________________
2001 - Pulled off monkey bars, landed directly on coccyx.
2006 - Sports injury that made it worse.
2016 - Multiple instances of paralyzing low-back pain.
2017 - Blew out my back on leg-press. MRI showed L5-S-1 disc herniation and grade 1 retrolisthesis.
2018 - Successful ADR surgery with Dr. Rolando Garcia using the Activ-L implant.
2019 - In physical therapy for burning in feet, L4-L5 diffuse disc bulge and SI joint pain.
2020 - Getting better with one-on-one PT.

30 - Male - American
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  #3  
Old 05-31-2019, 12:18 AM
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GravyBaby GravyBaby is offline
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Join Date: Mar 2018
Posts: 132
Default

Small update to my insurance post-prior authorization denial:

My surgeon's office submitted my info to Aesculap, the developer of my artificial disc, and they have taken my case up to go through the appeal process on my behalf.
__________________
2001 - Pulled off monkey bars, landed directly on coccyx.
2006 - Sports injury that made it worse.
2016 - Multiple instances of paralyzing low-back pain.
2017 - Blew out my back on leg-press. MRI showed L5-S-1 disc herniation and grade 1 retrolisthesis.
2018 - Successful ADR surgery with Dr. Rolando Garcia using the Activ-L implant.
2019 - In physical therapy for burning in feet, L4-L5 diffuse disc bulge and SI joint pain.
2020 - Getting better with one-on-one PT.

30 - Male - American
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  #4  
Old 08-19-2019, 09:00 PM
Cheryl0331 Cheryl0331 is offline
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Join Date: Dec 2010
Posts: 806
Default I will never understand

Why would an insurance company want to pay for a fusion that will lead to more surgery, when an ADR will save them money in the long run?!!!
It is absolutely absurd!
__________________
53 yr old 5ft.7in. 141 lbs. non-smoker conservative treatments failed
2007 fusion C4-6 w/peek implants plate & screws, failed due to long term use of cox-2 inhibitor
2008 revised w/donor bone replace plate & screws
2009 fusion Roi-C C3-4
2015 MRI & CT shows incomplete fusion, significant central canal narrows C3-4, mild posterior spurs C4-6, mjr ddd C6-7, segmental kyphosis at C7-T1 2-level ADR with Dr. Clavel
2019 some ddd C2-3 occipital nerve pain , HO behind ADR C6-7.

Last edited by Cheryl0331; 08-19-2019 at 09:01 PM. Reason: Typo
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  #5  
Old 08-09-2020, 11:43 AM
Cheryl0331 Cheryl0331 is offline
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Join Date: Dec 2010
Posts: 806
Default Long overdue after thought

If an insurance company approved you, then denies you after the fact; Ibwould hold them liable became you might have not proceeded and have that expense all on your shoulders.
__________________
53 yr old 5ft.7in. 141 lbs. non-smoker conservative treatments failed
2007 fusion C4-6 w/peek implants plate & screws, failed due to long term use of cox-2 inhibitor
2008 revised w/donor bone replace plate & screws
2009 fusion Roi-C C3-4
2015 MRI & CT shows incomplete fusion, significant central canal narrows C3-4, mild posterior spurs C4-6, mjr ddd C6-7, segmental kyphosis at C7-T1 2-level ADR with Dr. Clavel
2019 some ddd C2-3 occipital nerve pain , HO behind ADR C6-7.
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  #6  
Old 08-19-2020, 11:58 AM
GravyBaby's Avatar
GravyBaby GravyBaby is offline
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Join Date: Mar 2018
Posts: 132
Default

Hi Cheryl,

So I did call the state insurance board shortly after my initial denial and they informed me that it is legal for them to do that. Now, is it right? Of course not! But they do it anyway.

In any case, I forgot to update in the winter, BCBS of Florida or Florida Blue DID end up paying for my surgery.

It took a year and a half of appeals, but they finally paid on the final step of external appeal.

Thank goodness I did not get caught with the bill. I was prepared to file for bankruptcy.
__________________
2001 - Pulled off monkey bars, landed directly on coccyx.
2006 - Sports injury that made it worse.
2016 - Multiple instances of paralyzing low-back pain.
2017 - Blew out my back on leg-press. MRI showed L5-S-1 disc herniation and grade 1 retrolisthesis.
2018 - Successful ADR surgery with Dr. Rolando Garcia using the Activ-L implant.
2019 - In physical therapy for burning in feet, L4-L5 diffuse disc bulge and SI joint pain.
2020 - Getting better with one-on-one PT.

30 - Male - American
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  #7  
Old 08-19-2020, 02:21 PM
Cheryl0331 Cheryl0331 is offline
Senior Member
 
Join Date: Dec 2010
Posts: 806
Default Glad to hear it

Well alls well that ends well, but the stress of that appeal was something you shouldn't have had to go through.
__________________
53 yr old 5ft.7in. 141 lbs. non-smoker conservative treatments failed
2007 fusion C4-6 w/peek implants plate & screws, failed due to long term use of cox-2 inhibitor
2008 revised w/donor bone replace plate & screws
2009 fusion Roi-C C3-4
2015 MRI & CT shows incomplete fusion, significant central canal narrows C3-4, mild posterior spurs C4-6, mjr ddd C6-7, segmental kyphosis at C7-T1 2-level ADR with Dr. Clavel
2019 some ddd C2-3 occipital nerve pain , HO behind ADR C6-7.
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