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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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  #31  
Old 04-06-2011, 12:36 PM
tkdodger tkdodger is offline
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Join Date: Apr 2010
Posts: 10
Default adr friendly - not

Quote:
Originally Posted by Harrison View Post
The following insurance carriers have issued a positive coverage decision on the Prestige Cervical Artificial Disc:

BCBS Illinois

Source: 1-800-446-1234 or visit www.cinn.org. Original article here.
I have received notification from BCBSIL that ADR is still considered experimental, since no long term data is available to prove that is is BETTER than fusion. BCBSIL will NOT cover any costs associated with ADR procedure.
__________________
C5-6 herniation
C6-7 moderate bulge
3 auto accidents in 1986, 1987, 1988
Chiropractic, physical therapy, TENS, acupuncture, massage, epidural steroid injections
Metaxalone !!! Massage in a pill !!!
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  #32  
Old 07-10-2011, 08:49 PM
brianw48 brianw48 is offline
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Join Date: Jul 2011
Posts: 3
Default Approval Letter, and/or Appeal Letters - BCBS - CA

Does anyone have copies of Approval letters from Anthm/BCBS of California, for Cervical ADR?

I would very much like to have some names and examples of approvals for my appeal.

If you have an Appeal letter that worked with Anthm/BCBS of Californis, I would be interested in that as well.

Feel free to email to: brianw6212@gmail.com
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  #33  
Old 08-29-2011, 09:11 PM
semathes semathes is offline
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Join Date: Aug 2011
Posts: 6
Default Anthem BCBS hell(p)

I would like to join forces with anyone who has experience with Anthem BCBS or any other BCBS for that matter.

I'm in need of any successful coverages, appeals, court cases, etc. for lumbar ADR.
__________________
2007 lower back pain becomes continuous, original cause unknown
2010 physical therapy, xray, mri, pain meds, muscle relaxers
2011 diagnosed with bone on bone at L5-S1, bone loss occurring, 3x epidural steroids injections, continuous pain meds, ct scan, denied ADR by Anthem BCBS
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  #34  
Old 03-24-2015, 06:41 PM
Cheryl0331 Cheryl0331 is offline
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Join Date: Dec 2010
Posts: 759
Default Insurance re-imbursement for ADR w/prior fusion?

I have heard that some will pay 50% of what Medicare will cover, but what about next to a prior fusion? Has anyone here heard of an insurance company at least covering the Discectomy portion. They would still have to pay for that part of it with a fusion. Just reimburse the surgery cost and let us pay out-of-pocket for the ADR device.
__________________
52 yr old 5ft.7in. 139 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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  #35  
Old 03-24-2015, 08:15 PM
Jerry5 Jerry5 is offline
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Join Date: May 2013
Posts: 363
Default Not Cervical

But I would talk to your doctor about a Two Level Mobi-C, maybe you can have one of the Fusions removed, or above or below, or above and below, the mobi-c is approved for two levels.

The insurance is real funny, they will fight like the dickens, and say it is NOT approved, then go back at them, AFTER you have it done, and they will reimburse.
Risky, but it does work, in some cases.

First, Talk to your doctor about the Mobi-C, have them submit the paperwork to the insurance.
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Jerry, Somewhere Ohio

L2-3 herniation, two days before Thanksgiving, 2012, Discectomy/Laminectomy, 3/13 Numbness in the right leg, lateral femoral, gone, July 10, 2014 L45 M6 ADR, July 15 PLIF L5-S1, Not able to access L51 Anterior.
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  #36  
Old 03-24-2015, 11:43 PM
brandis77's Avatar
brandis77 brandis77 is offline
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Posts: 56
Default Bcbs tx

Just wanted to post that BCBS TX approved my 2 level cervical ADR with the Mobi-C, and it took them less than a week to approve.
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2012-14 Right arm/shoulder/neck pain and numbness, headaches, and nerve pain gradually becomes debilitating. Medications ineffective and PT impossible due to pain. Old MRI re-read, diagnosis of C4-6 herniations.
Jan 2015 2 epidural spinal injections ineffective.
Feb 2015 2-level ADR C4-6 with Mobi-C with DrPeterson in Austin (approved by BCBSTX)
May 2015 Microdiscectomy for herniated L4/5
Oct 2015 L4/5 ESI ineffective, microdiscectomy "redo"
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  #37  
Old 03-27-2015, 05:46 PM
Cheryl0331 Cheryl0331 is offline
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Default not if you have the slightest Adj level ddd

mobi-c will be great for two level but if the disc above/below are even iffy, I would want the m6; that said, insur wil pay for two level mobi-c so I'd go for it! I can't do it though with a prior fusion. Blumenthal's Pat. Coord said I was not a candidate.
__________________
52 yr old 5ft.7in. 139 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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  #38  
Old 03-28-2015, 03:52 AM
Cheryl0331 Cheryl0331 is offline
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Join Date: Dec 2010
Posts: 759
Default i have had doctor tell me that fusion can't be reversed

Quote:
Originally Posted by Jerry5 View Post
But I would talk to your doctor about a Two Level Mobi-C, maybe you can have one of the Fusions removed, or above or below, or above and below, the mobi-c is approved for two levels.

The insurance is real funny, they will fight like the dickens, and say it is NOT approved, then go back at them, AFTER you have it done, and they will reimburse.
Risky, but it does work, in some cases.

First, Talk to your doctor about the Mobi-C, have them submit the paperwork to the insurance.
Then I read about Dr. Katzman in FL. and Dr. Kenneth Light in CA. so are they for real? I think if I got the M6 at C 6/7/T1 then had the PEEK cage removed at C 3/4, I might have my life back.
__________________
52 yr old 5ft.7in. 139 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; 03-28-2015 at 04:03 AM. Reason: wrong doctor listed
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  #39  
Old 03-28-2015, 04:05 AM
Cheryl0331 Cheryl0331 is offline
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Join Date: Dec 2010
Posts: 759
Default Should you even try to get pre authorization?

Or just go have it done anyway and beg later??? That way they can't say, "we told you and you did it anyway, now you want us to pay"
__________________
52 yr old 5ft.7in. 139 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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  #40  
Old 03-28-2015, 10:59 AM
Jerry5 Jerry5 is offline
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Join Date: May 2013
Posts: 363
Default Pre Authrorization

Cheryl,
Go ahead and send the MRI/xrays to Bierstedt, (there are others) (the USA does not allow the M6 to be implanted, yet) and get the recommendation from them, submit this to your insurance.

If they deny, they most likely will, then if you can afford it, take it out of a 401 or some other savings, pay for it, then send the Bill to the insurance, for reimbursement.

Most likely they will deny this, but use all your apples, tests, doctor visits, medications, trouble at work, trouble in life, list all, list all the problems, then APPEAL, and APPEAL again.

All the best, and best of luck, the M6 is the best choice, unless you can have the mobi c placed at the lowest level that is giving you trouble(C7T1), then fuse further up, from what other people that have cervical have told me,
Maybe do a hybrid, one level mobi-c, then fusion, or cage, then another level mobi-c then another fusion, this would be 4 levels?
__________________
Jerry, Somewhere Ohio

L2-3 herniation, two days before Thanksgiving, 2012, Discectomy/Laminectomy, 3/13 Numbness in the right leg, lateral femoral, gone, July 10, 2014 L45 M6 ADR, July 15 PLIF L5-S1, Not able to access L51 Anterior.
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