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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 11-26-2016, 08:45 PM
Nestletea Nestletea is offline
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Join Date: Nov 2016
Posts: 33
Default Florida Blue -Post C5/C6 Denial

For those of you struggling with insurance authorizations, I wanted to share my story regarding the mobi-c C5/C6 disc replacement surgery I had on 3/17/16. My neurosurgeons office failed to receive prior authorization and the surgery was denied after the fact. Imagine the surprise when I opened a letter from Florida Blue stating that the cervical surgery had been denied due to not being medically necessary. I had been through months of conservative therapy (chiropractic, PT, and pain management). I had severe weakness in my right arm and wrist extensor, which was confirmed by a NCV/EMG. The neurosurgeons office tried to appeal the insurance decision several times and failed. Ultimately, I ended up filing my own appeal. The mobi-c patient advocacy group was extremely helpful in providing research documentation to send in with my appeal. My chiropractor and physical therapist both wrote letters on my behalf. Guess what? I won my appeal on the first attempt. I would be more than happy to share how I put my packet together if anyone needs help.
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1/8/2016 - Microdiscectomy L5/S1
3/17/2016 - Cervical Disc Replacement C5/C6 (Mobi-C)
10/19/2016 - DeKompressor Wand L5/S1
1/16/2017 - Cervical Radiofrequency Lesioning
3/15/2017 - Dr. Pablo Clavel: Cervical Disc Revision C5/C6 (M6-C) and Lumbar Disc Replacement (M6-L)
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  #2  
Old 11-27-2016, 10:03 PM
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Harrison Harrison is offline
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Join Date: Oct 2004
Posts: 6,883
Wink Congrats

That's great news! Continued success on your healing. Pls remember to take good care of your teeth and gums for the rest of you life! Yes, it's all related....

Pls see my biofilm channel, there are several on the dental-systemic connection:

https://www.youtube.com/user/ADRSupport/videos
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"Harrison" - info (at) adrsupport.org
Fell on my ***winter 2003, Canceled fusion April 6 2004
Reborn June 25th, 2004, L5-S1 ADR Charite in Boston
Founder & moderator of ADRSupport - 2004
Founder Arthroplasty Patient Foundation a 501(c)(3) - 2006
Creator & producer, Why Am I Still Sick? - 2012
Donate www.arthropatient.org/about/donate
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  #3  
Old 12-09-2016, 07:08 AM
WakesurfMike WakesurfMike is offline
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Join Date: Nov 2016
Posts: 37
Default I would like a copy of what you submited

I would like a copy of what you submitted. My Dr just submitted for authorization to Blue Cross. I am expecting to receive a denial
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WakesurfMike
2007 Herniated L5/S1 Lifting changing X-ray tube at work. MRI PT/ Steroid shots/med
2009 switched to Remote/phone support
2010 workman’s comp lawsuit
2011 Microdiscectomy approved 80% pain relief
2011-2016 few flare ups but would always get beter after a few days.
6/2016 Pain is not going way
07/2016 MRI, tramodol, Nucynta, Celebrex
08/2016 Regenerxx PL-Disc shot- didn’t work at all
10/2016 can't even stand or sit for work for 30 minutes before pain gets worse
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  #4  
Old 12-21-2016, 09:03 AM
WakesurfMike WakesurfMike is offline
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Join Date: Nov 2016
Posts: 37
Default Update. I actually got approval on first request with Anthem Blue Cross

Update. I actually got approval on first request with Anthem Blue Cross
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WakesurfMike
2007 Herniated L5/S1 Lifting changing X-ray tube at work. MRI PT/ Steroid shots/med
2009 switched to Remote/phone support
2010 workman’s comp lawsuit
2011 Microdiscectomy approved 80% pain relief
2011-2016 few flare ups but would always get beter after a few days.
6/2016 Pain is not going way
07/2016 MRI, tramodol, Nucynta, Celebrex
08/2016 Regenerxx PL-Disc shot- didn’t work at all
10/2016 can't even stand or sit for work for 30 minutes before pain gets worse
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  #5  
Old 12-21-2016, 05:18 PM
pittpete pittpete is offline
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Join Date: Jan 2008
Posts: 307
Default

Awesome
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Born 1970/1995-Hurt at work/1996-Right disc fragment L4-L5 discectomy-On/off back pain,no serious leg pain until/2007-Right herniation L5-S1,recurrent small herniation at L4-L5 with unbearable leg pain/6/08 discectomy L5-S1/leg pain relieved/occaisional mechanical pain/2012-Cymblata 60 mg,occasional aleve/2014-LB pain not debilitating but chronic,Rhizotomy relieves facet pain on right side/2015-L4-S1 facets shot/4/15 PLIF L4-S1 with facectomy
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  #6  
Old 04-17-2018, 07:00 PM
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nginla nginla is offline
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Join Date: Oct 2017
Posts: 7
Default

Hi - I had an L4-5 ADR with Dr. Clavel 4 months ago. Filed the international claim with BCBS, who sent it to my local BCBS of MN who denied it all saying it was not a medical necessity and that the procedure is therefore not approved. Can you please share with me how to go about the appeal process? I will really appreciate it. I am trying to get as much information frm all successful appeal candidates so that I put the package together as best as possible! It appears I cannot private message you. Thank you,
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47 yr old biochemist/golfer in Los Angeles
7 years back and neck pain; L4-5 annular tear, C5-6 herniation
2015/16: PT, Acupuncture, epidural/facet injections
2015: 4th cranial nerve palsy and double vision/vertical strabismus, not sure if related in any way to neck/back
2017: Scheduling for L4-5 ADR in LA, insurance pushback
2017: Looking at ADR in Europe now
12/14/17: L4-5 ADR by Dr. Clavel, Spain
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  #7  
Old 04-17-2018, 08:35 PM
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GravyBaby GravyBaby is offline
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Join Date: Mar 2018
Posts: 130
Default

Hey Nestletea,

Did you get BCBS to pay for your lumbar disc with with Doctor Clavel as well?

Best,
__________________
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.

29 - Male - American
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