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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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  #11  
Old 11-16-2008, 11:41 PM
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KBear KBear is offline
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Question Who paid for your ADR?

I would love to hear from more on the surgical outcome forum as to who paid for their surgery? Did they? Or did Insurance? I think this is equally important as denials, so those of us trying to get it know if there is a precedent.
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  #12  
Old 11-17-2008, 09:28 PM
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Terry Terry is offline
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There has been a precedent set in Michigan by several recipients of ADR surgeries done in Germany and paid for by Blue Cross/Blue Shield of Michigan. They originally denied my surgery a couple of times and then paid for it.

I always thought they were a good insurance company and they have taken good care of my employees and their families for many years. I have covered almost all of our employees, their spouses and, all children living at home for the 18 years that I have been the director of the company.

I am very pleased with our insurance carrier.

Terry Newton
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1980 ruptured L4-L5
1988 ruptured SI-L5
1990 ruptured C5-C6
1994 ruptured C6-C7
1995 Hemi-Laminectomy C5-C6, C6-C7 Mayo Clinic
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  #13  
Old 02-16-2009, 01:18 PM
Deborah Deborah is offline
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In researching how to get my hubs hybrid surgery covered, I did get this list from Prodisc (in late Nov). So far, not many are hopping on board, but that is changing! Most important, it requires a doctor willing to advocate for the patient and prove the proposed procedure is appropriate. Here's the list I have (and hope to add at least one more very soon):

Aetna routinely approves LADR, and it has been approved by Signa in Arizona, Arkansas, Montana and New Jersey, Blue Cross, Capital Health, Great West Healthcare, Gunderson Health, Intermountain Healthcare, Kaiser Permanente, Washington State Employee Health Plan.

That list doesn't mean it's at all easy to get it approved, but it's been done, so it's possible given the right patient and circumstances. Aetna seems the only one that considers ADR like any other treatment and I'm sure there are more... these are just what they were able to tell me that had been told were covered.
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  #14  
Old 02-16-2009, 07:19 PM
JasonR JasonR is offline
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Quote:
Originally Posted by Deborah View Post
In researching how to get my hubs hybrid surgery covered, I did get this list from Prodisc (in late Nov). So far, not many are hopping on board, but that is changing! Most important, it requires a doctor willing to advocate for the patient and prove the proposed procedure is appropriate. Here's the list I have (and hope to add at least one more very soon):

Aetna routinely approves LADR, and it has been approved by Signa in Arizona, Arkansas, Montana and New Jersey, Blue Cross, Capital Health, Great West Healthcare, Gunderson Health, Intermountain Healthcare, Kaiser Permanente, Washington State Employee Health Plan.

That list doesn't mean it's at all easy to get it approved, but it's been done, so it's possible given the right patient and circumstances. Aetna seems the only one that considers ADR like any other treatment and I'm sure there are more... these are just what they were able to tell me that had been told were covered.
FWIW, Great West denied my cervical ADR a little over a year ago. Maybe they approve lumbar ADR?
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  #15  
Old 05-10-2009, 11:47 PM
monisavant monisavant is offline
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Default Excuse me-

I'm new here but did someone say that Aetna might cover ADR?
Sorry I'm excited that there is even a slight possibility. Been sitting here brewing all day over the fact that the procedure is not covered in the US since I just found out about the stenum hospital .
My Orthopedic surgeon wants to do the Fusion of c3-4 and c5-6.

Is it a remote possibility that Aetna might cover Cervical ADR?
Does anyone know.
Thanks for all the postings. I have been a long time sufferer and keep "stumbling" onto treatments. The medical community steers you in the direction they want you to go.
The rest I have found out on my own which is BS.
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  #16  
Old 05-11-2009, 02:25 AM
koroni koroni is offline
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Default 3 level Prodisc C covered by Premera BC in Germany

OK, I don't know if this is a news flash or what, but after 2 months of phone calls and documentation, my Premera Blue Cross plan pre-authorized my multilevel ADR with Dr. Bertagnoli in Germany. I had just refinanced my house to send off the payment in the 3 weeks in advance of my surgery, which took place mid-April, almost 4 weeks ago. (very happy with my results so far, BTW). What a relief to know that my daughter can go to college next year. Dr. B's billing staff honestly didn't know what to do with my pre-authorization letter - they knew it was legit, but I gathered they were surprised that I only had to pay just over $400 in co-pays.

So here's what I know: If you have BC and your card shows a suitcase that has something inside it (like PPO), you have international coverage. I made a lot of anonymous, or 'hypothetically speaking' phone calls before submitting my request for coverage. I took the advice found here and on ProSpine's site, and got plenty of support from Tom Vicknair, who works with Prospine to assist the uninitiated. In the end, it all worked out. I still don't know exactly what did it. I argued that it would be cheaper, I was eligible for overseas coverage and should be held to the standard in the country where it would be performed, and I was willing to incur all the costs of rendering myself to Germany, including any follow-up care and expenses. I also sent my letter of medical necessity, abstracts of Dr B's research, peer-reviewed studies that show that ADR is of the greatest benefit for people like me who need multiple levels replaced. I also added that it would be at least 1/2 the cost of fusion here. Of course, it's possible that none of these factors had anything to do with thier decision, but I think that the major savings to them, and my willingness to go to where FDA approval was meaningless were what did it. I guess I'll never know.

One more thing: Be persistent, but polite, and call back to speak with a different CS rep until you talk to someone who seems sympathetic. Ask for advice in getting it approved. I was coached in what to include to support my claim, and I went to work gathering all the documentation I could. Also, Premera is my secondary insurance, and they told me at the onset that they don't pre-authorize for secondary and I would have to submit the bills after the fact. I told them that I had already been denied by my primary and that I didn't have the funds to do it that way. I had given up. Then I made that last call, just hoping that maybe - somehow - some miracle would occur. The rep I worked with was very supportive and seemed genuinely thrilled to tell me it had been approved and the pre-authorization letter was being prepared. So don't give up!

Hope this helps.
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  #17  
Old 05-11-2009, 10:36 AM
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Harrison Harrison is offline
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Exclamation Moni, Koroni....Holy Macaroni!

Hi Moni,

Yes, see the first post in this topic -- Aetna has covered one level ADRs for some time -- starting with one-level lumbar ADR. I honestly have not see their stated policy describing cervical ADR, but some patients have been already covered for that! They have also covered hybrid procedures (one ADR, one fusion). I cannot confirm if they have covered two-level cervical ADRs.

Koroni, that's great news and not something you hear every day! It's great you have a PPO. If one can afford these kinds of plans, it's definitely a better plan to have.
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  #18  
Old 05-11-2009, 11:56 AM
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trkdoc714 trkdoc714 is offline
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Aetna's Clinical Policy Bulletin #0591 outlines the FDA approved lumbar and cervical disc replacement as medically necessary (after 6 weeks of conservative therapies) for a single level only. The CPB was updated 3/10/09.

Bob
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06/06 Diskectomy/ Laminotomy L5/S1
04/07 Recurrent Disc L5/S1
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03/27/09 L4/5 & L5/S1 Maverick disc at Stenum
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  #19  
Old 05-20-2009, 03:31 PM
Sondralp Sondralp is offline
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Exclamation Anyone had luck with BCBS covering in Germany

I recently had ADR surgery in Germany. I had the Maverick device placed. I understand that the FDA is close to approval, is this true? I am looking for any advise to help with my insurance appeal letter!

Thanks,
Sondra
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  #20  
Old 06-04-2009, 12:04 AM
Frankg Frankg is offline
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Default Has UHC EVER paid?

Does anyone know of even one documented case in which UHC has paid for ADR either in the US or abroad?
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