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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 03-06-2017, 11:57 PM
ouchtear ouchtear is offline
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Default BCBS of NEW YORK DENIED

After months and months of internal appeals and finally a external appeal from New York state it was finally denied. I was going to have a one level l5-s1 done with either a Prodisc L or Activ L at the Texas Back institute. It's such bull****.. No evidence to support it is better than fusion... Then with that logic there is NO evidence to support that it is worse. So then let me chose then... I guess I am at square 1 again.. I may just take a gamble and pay for it out of pocket somewhere...submit it and then fight them like hell to pay for it..
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  #2  
Old 03-08-2017, 11:41 AM
Nestletea Nestletea is offline
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Posts: 33
Default Texas Back Institute

Texas back institute will do an all inclusive package - $36,000. However, this does not include hotels and transportation. I had the same insurance issues with BCBS and went through the appeals process. I have decided on Barcelona Spine Center and have surgery scheduled on March 15th at the L5/S1 level utilizing the M6L. The total cost including hotel and transportation is $30,000.

Best of Luck!

Leanne
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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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  #3  
Old 03-09-2017, 10:45 PM
ouchtear ouchtear is offline
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Default

Thanks, Yes I know about Texas Back Institute that is where I actually went. I have also had a quote from Doctor Clavel too. I would need a loan and there really are no long term loans out there for this that I can find.. there are 5 year loans.. but I would need around 10. I wish you the best with your ADR. The euro has dropped quite a bit to the dollar so that is good right now.
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Last edited by ouchtear; 03-09-2017 at 10:48 PM. Reason: adding more
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  #4  
Old 05-10-2017, 03:21 AM
LumbarSpine LumbarSpine is offline
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Default

I would argue that there IS evidence that ADR is better than fusion. I can't speak to your specific case, but in general, ADR is motion preserving, and reduces by a lot (I believe the study I read said over 3X) the chances that you will have adjacent segment problems. I feel like this is a case of knowing what literature is available to support your arguments. Perhaps you already know and they are ignoring it, but if not, keep in mind that there certainly are studies that show ADR is superior to fusion. If I recall correctly, some studies mention faster recovery also.
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* 40's, otherwise healthy, back pain for many years.
* DDD at L4/L5. Facet pain at same level.
* Multiple RF ablations, with inconsistent/marginal results.
* Single-level disc replacement with Dr. Clavel, Sept. 2017. Went well, recovery MUCH faster and less painful than anticipated. Now need to get active again and keep back in shape!
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  #5  
Old 05-15-2017, 11:02 AM
ouchtear ouchtear is offline
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Yes.. That is the evidence that I agree with too. It was 3 independent Doctors in New York State that make the final decision on the External appeal. 3 morons if you ask me.. If they are not morons then it has to be only one thing.. a conspiracy to make a lot of money at not actually fixing the problem.. Drug-surgery-drug more-surgery more etc....etc...Just think of the billions of dollars every year spent on spinal injections alone.
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  #6  
Old 10-14-2017, 09:31 PM
ia75 ia75 is offline
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I agree! The BCBS FEP "expert" who denied my appeal is Dr Santamaris and specializes in hospice/palliative care. I never even had a chance, what a Scharade this appeals process is Not sure if switching to another insurance would have a better outcome...
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  #7  
Old 10-16-2017, 01:38 PM
GKTM300 GKTM300 is offline
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Default Well

If you do your research n appeal it with a good argument I don't seek how they can't pay. Also I was told fusion ain't so bad if done correctly. I was told the hardware is suppose to be temporary and that the pad and two pedicles are fused and hardware taken out a year later.
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12/22/04 blew L4-5 and L5-S1 out lifting wrong
4/1/05 back to work thanks to Oxy
11/11/13 hurt back lifting again
6/6/15 last of many MRI L4-5 medium paracentral bulge with juice leaking and mid to left bulge on L5-S1
No invasive procedures except steroid shots that did nothing n hurt wicked bad
9/24/2016 Adr surgery Bertagnoli>1 year doing great
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  #8  
Old 10-16-2017, 08:34 PM
pittpete pittpete is offline
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Default

I had L4-S1 fused 2+ years ago.. I'm doing 100x better than presurgery.
No reason to remove hardware if it isnt causing issues.
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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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  #9  
Old 10-23-2017, 12:27 PM
GKTM300 GKTM300 is offline
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Join Date: Dec 2015
Posts: 273
Default Lawyer

There's a lawyer in San Fran I think he is listed on a Adr dr web site. He has been fighting n winning these cases for people w bcbs federal amount others I think he gets 10 percent. I haven't spoken w him I made a deal w myself if it worked I didn't mind paying
__________________
12/22/04 blew L4-5 and L5-S1 out lifting wrong
4/1/05 back to work thanks to Oxy
11/11/13 hurt back lifting again
6/6/15 last of many MRI L4-5 medium paracentral bulge with juice leaking and mid to left bulge on L5-S1
No invasive procedures except steroid shots that did nothing n hurt wicked bad
9/24/2016 Adr surgery Bertagnoli>1 year doing great
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  #10  
Old 11-14-2017, 01:28 PM
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Harrison Harrison is offline
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Default

Contact Laurie:

http://www.theinsurancewarrior.com/

She's better than a lawyer and more effective. I've not spoken with her for years; I hope she's still in the business!
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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
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