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The Big File All issues not easily categorized in the above forums are here. Comments on general health, diet, "getting comfortable," and more are here.


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  #1  
Old 06-06-2005, 01:53 PM
bmills bmills is offline
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Well, received the results from the final appeal last week. Surprise surprise, the external review organization's peer doctor upheld the insurance company's denail for ADR.

Where can they find these external doctors that agree with the insurance company but no experienced doctor you see agrees that fusion is the best recommendation?

Very seriously considering a law suit. I've got what seems to be an attorney very good at these types of cases. She is researching my case this week with two chief's of surgery at two large Denver hospitals this week.

The question I am facing is; pay for the ADR or pay an attorney to file suit and possibly to take it to court if its not settled prior to that. I'm hearing that if it goes to court, it usually is in favor of the individual and not the insurance company.

There is still the option to fuse and not have to pay.

Brady
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15+ yrs chronic low back pain.
L5/S1 DDD
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  #2  
Old 06-07-2005, 03:51 AM
Kat Kat is offline
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I am fairly new here but it seems alot of us are in a similar boat...insurance won't pay for ADR so either you fuse, pay yourself or keep fighting the insurance. The real question is how much longer can you live with the pain. I keep thinking I can hang on a little longer, but then I have a bad pain day and just want this ordeal over with.
If you take it to court, what sort of time frame are you looking at? I think ultimately, insurance companies will start paying for ADR and by time your case is heard, it could be a mute point.
Good luck with your decision!

Kat
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1/91 Fell L4/5 L5/S1 herniation
11/92 disketomy-No pain!
3/03 Pain L4/5 L5/S1 DDD
5/04 TBI/Dr Zigler recommends 1 level ADR
4/05 UHC denies Charite. Appealed-Denied again
6/05 Scheduled fusion 6/28
6/05 Fusion cnxl'd-
6/05 Fusion w/NS 7/26 at 7:30am
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  #3  
Old 06-07-2005, 02:13 PM
bmills bmills is offline
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Hard to say on the time frame. The hope is that they settle and there is no need to go to court. Could take a few weeks or up to months to know that answer. That could cost about $5,000 to get to that point and know if they settle.

Actually going to court is another whole story.

Brady
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15+ yrs chronic low back pain.
L5/S1 DDD
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  #4  
Old 06-07-2005, 04:59 PM
amanda amanda is offline
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I've been trying to get my husband approved for ADR since February with UHC. I just got a NO on our appeal. I went to the bank today to get a loan so he can go to Stenum in Germany for surgerty in July. I will continue to fight with the insurance company, but it is frustrating. I have asked them if they will pay for anything (hospital, anesthisia, etc), and I'm not able to get a straight answer.
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  #5  
Old 06-07-2005, 05:50 PM
NCFUSED NCFUSED is offline
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Brady,

Sorry to hear about your appeal. Before having my fusion, I talked to a lawyer about possibly filing a civil suit, unfortunately, becasue my company is self funded and UHC is only the administrator, I would have had to sue my employer, which besides them having hundreds of lawyers at their disposal, would have been career suicide on my part. A friend of my family that is an HR director for mywife's company didnt think it was a good idea either.....

Sadly, Insurance companies and big corporations have us where they want us right now. What really gets me is that the bills for my fusion are starting to come in now, and I really dont see much of a savings from the cost of the ADR surgery????

Oh well.....

Best of Luck to You, whichever course of action you take!!!

John
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John
Greensboro, NC
DDD L5-S1
Lost all ADR Appeals w/ UHC PLIF Fusion L5-S1 on 5/17/05.
Pars Defect L3-L4
DDD L3-L4 L4-L5
3 LVL Fusion Scheduled 4/08
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  #6  
Old 06-07-2005, 06:11 PM
APS APS is offline
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Brady,
Sorry to hear the bad news. I'll be most curious to hear what your attorney has to say. That's a tough decison you're faced with - best of luck. If I can help or answer any court-type questions, let me know. Unfortunately my background is not insurance law - I wish it was now!

As for me, doesn't look like I'll be any better off with UHC.

Hang in there,
Andrea
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Andrea
Grand Junction/Denver, CO

Failed L4-5 diskectomies '93 & '00
ADR originally scheduled 3/9/05; dropped insurance appeal due to new job; new insurance UHC
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  #7  
Old 06-07-2005, 11:27 PM
ans ans is offline
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Brady, sorry to hear this. Somewhere, somehow they'll cave in.

Best, Allan
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Severe, extensive DDD, considered inoperable by Dr. Regan, Lauressen, & some guy at UCLA. Severe foraminal stenosis (guess they can't operate!) and some spinal cord compression that Lauryssen would fix if gets outta hand.
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  #8  
Old 06-09-2005, 07:09 PM
bmills bmills is offline
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I will keep you posted. My doctor who was a principal investigator for the Charite feels I would do well with fusion or ADR at L5/S1. One thing is for sure, its not getting any better by not doing one or the other.

I just really don't want the recovery issues with fusion but there are of course similar difficulties with ADR recovery.

For now I will wait to see what the attorney thinks about the case after researching it all.

John, I emailed you to see how you are doing with the fusion. Hope you are feeling good.

Thanks.
Brady
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15+ yrs chronic low back pain.
L5/S1 DDD
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  #9  
Old 06-14-2005, 09:46 AM
kt kt is offline
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Does anyone know if Medicare is paying for ADR? I heard they don't pre approve.

Thanks,
Kim
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  #10  
Old 06-14-2005, 11:35 PM
Kim Kim is offline
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http://www.spine-health.com/topics/s...charite03.html
I thought I had read somehwere about Medicare reimbursement rates for Charite. Check out the above link. Evidentally they are at least considering it for Medicare and Medicaid as they have reimbursment rates in place. They are not the best as far as reimbursment goes but it shows that they have been considered and have a schedule in place.
Hope this helps
Kim
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Kim
Herniated disc L5/S1 2000 Discectomy 10/2003 Rhizotomy 8/2004 and 3/2005Discogram 11/04 grade 7 tear L5/S1
L4/L5 Grade 5 tear with herniation and stenosis
Evaluated by Dr Blumenthal at TBI
2/2005 ADR 2 level recommended
2 level lumbar fusion
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