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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 01-28-2009, 07:08 PM
gclc1457 gclc1457 is offline
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Default 2nd Appeal denied by UHC

Hi everyone,

i received bad news today. United hellcare denied me again for adr surgery. My doctor and i have submitted all the correct paperwork, but they continually state that it is an unproven service. I am disgusted with the way they handle the matter, and the treatment you receive from the customer service dept. I was told that its unproven because they don't know the long term effects relating to adr surgery. I hope they don't think they are do this in my best interest. If anyone can give me some advice i could really use it. I really don't want to have a fusion, but i'm aggrevated and in pain.

Thank you
gary
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  #2  
Old 02-01-2009, 06:57 PM
trucklt trucklt is offline
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Join Date: Sep 2008
Posts: 37
Angry UHC Stinks!

Hi,

I have the NY State Health Insurance Plan for public employees. It's a hybrid plan of Blue Cross/Blue Shield for hospitalization and UHC for medical/surgical. They work together under what is called the "Empire Plan" to limit care as much as possible in order to keep up their quarterly profits. That's probably the kindest thing that I can say about either of them.

I fought them in 2005 for months over a Charite ADR. Apparently they haven't changed their position in 4 years: ADR is unproven technology. The unspoken message I got from them was "get a fusion or stop bothering us."

Under you state's insurance laws, you should be able to appeal to a neutral fact finding panel. If your insurance company hasn't provided the information about an "external appeal" process, contact your state insurance department for information. Before you do your final external appeal, make sure that you have covered all the bases such as failure of at least six months of conservative treatment such as P.T., injections, chiropractic, etc., recent MRI and discograms, and diagnostic nerve root blocks and facet injections to eliminate ANY doubt that your problem is disc related. You will also likely need to provide scientific studies that show the long-term efficacy of ADR. I spent a lot of time in medical libraries and found some good long-term studies about Charite, but they were all from Europe.

I lost my "external appeal" by a vote of 2 to 1. One of the "no" votes just hated ADR and wouldn't approve it for anyone. The other "no" vote made a big deal that I hadn't had facet injections and felt that my workup was incomplete. I later had the facet injections and they weren't the problem. I also got the feeling that the doctors on the review panel could care less about scientific studies done outside the US.

I tried to tough it out in the hope that UHC and BCBS would change their policies on ADR. Unfortunately, I've hit the end of the line and am having a single-level fusion on Feb. 10.

I hope that you have better luck fighting UHC. UHC and BCBS are noted on this forum as being the toughtest to move on ADRs.
__________________
Diagnosed with L4/L5 DDD 1998 after lifting injury.
10 years of failed P.T., Chiropractic, Acupuncture, injections.
Turned down for ADR in 2005 by United Healthcare
Living on Ultracet and Vicodin ES and only working part-time
Disqualified from Active-L trial due to low bone density in spine
ALIF 02/10/09
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  #3  
Old 02-01-2009, 08:39 PM
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Harrison Harrison is offline
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Default

Gary, thanks for making me laugh in spite of your hardship (United hellcare?!). This company has approved well over 150 ADRs, through accident, appeals or mistakes. Sorry your case was not approved. PM or email me if you are still appealing; I will try to help.

Truck, I am sorry about the news, but thanks for sharing your well-fought battles with us. It will help others. And hey, fusion is not the end of the road -- it's still a good procedure that has 100 years of experience behind it! Keep us posted on the news of your future fusion. And at least you have a milestone to work towards!
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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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  #4  
Old 02-02-2009, 10:22 PM
Liz Liz is offline
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Default UHC ADR approvals?

Quote:
Originally Posted by Harrison View Post
This company has approved well over 150 ADRs, through accident, appeals or mistakes.
Richard -- just curious but how do you know UHC has approved well over 150 ADRs? i am shocked to read this as i just asked my surgeon's office last week if UHC was now approving ADR. my surgeon has performed well over 700 ADRs and has only had ONE single-level case approved by UHC in 2005 after a year long battle. if over 150 are getting approved, then more should. if you have some of these approval letters then maybe you can help Gary.

Gary -- good luck. if you really want an ADR your surgeon should have some ADR articles that may support your appeal and i would ask for a copy of UHC's policy w/your employer and UHC's technology assessment to use when arguing your appeal. even though i'm not an ADR success, i think ADR should be authorized since it's FDA approved if you and your surgeon feel it's medically necessary, you meet the inclusion criteria, and if it's the best treatment option for your condition. it's absurd.

best,
Liz
__________________
scoliosis; 1998 snowboarding injury->DDD L3-S1 w/annular tears/protrusions; 2007 episodes of rt foot drop
2007 Prodisc ADR L4-S1
L4-5 Prodisc tilted/facet issues; old L5 nerve damage
2009 L4-5 Prodisc ADR removed and revised to XLIF w/posterior instrumentation
massive hemorrhage from tear of inferior vena cava at right iliac vein due to adhesion from Prodisc op
2010 not fused; as a result of complications permanent nerve damage to lumbar plexus causing severe rt leg, hip, groin pain
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  #5  
Old 02-02-2009, 11:14 PM
Liz Liz is offline
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Join Date: Oct 2007
Posts: 195
Default ADR clinical trials

ps... Gary, have you considered an ADR clinical trial if you are unable to get UHC authorization?? i think some of the Activ-L sites are still open and of course new trials are starting all the time. I really don't keep up w/the trials anymore but I'm sure there are people on here that could help you, or perhaps your surgeon could direct you somewhere.

best,
Liz
__________________
scoliosis; 1998 snowboarding injury->DDD L3-S1 w/annular tears/protrusions; 2007 episodes of rt foot drop
2007 Prodisc ADR L4-S1
L4-5 Prodisc tilted/facet issues; old L5 nerve damage
2009 L4-5 Prodisc ADR removed and revised to XLIF w/posterior instrumentation
massive hemorrhage from tear of inferior vena cava at right iliac vein due to adhesion from Prodisc op
2010 not fused; as a result of complications permanent nerve damage to lumbar plexus causing severe rt leg, hip, groin pain
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  #6  
Old 02-03-2009, 02:32 PM
treefrog treefrog is offline
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Default

Truck - the neurosurgeon that I had a second opinion with said that the European system is not as good as our FDA process, and that is why he doesn't trust what little data they have.

It's a shame, because I don't think that the FDA process is necessarily any better. There are a lot of flaws in data that comes from clinical trials in the US too.

Bottom line for us spine patients though - it sucks.
__________________
Cathy
MRI 12/07
L4-5 Mild-moderate disc degeneration with dessication.
L5-S1 Mild disc degeneration with dessication, minimal disc bulging.

PT/medication/acupuncture/ESI's/facet injection

Discogram 12/3/08 confirmed L4/L5 & L5/S1 as pain generators.
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  #7  
Old 02-07-2009, 06:05 AM
Robert G Robert G is offline
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Join Date: Jan 2009
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Default

Quote:
Originally Posted by gclc1457 View Post
Hi everyone,

i received bad news today. United hellcare denied me again for adr surgery. My doctor and i have submitted all the correct paperwork, but they continually state that it is an unproven service. I am disgusted with the way they handle the matter, and the treatment you receive from the customer service dept. I was told that its unproven because they don't know the long term effects relating to adr surgery. I hope they don't think they are do this in my best interest. If anyone can give me some advice i could really use it. I really don't want to have a fusion, but i'm aggrevated and in pain.

Thank you
gary
You state that the denial was based on the assertion that ADR is unproven long term. But how does that assertion relate to the specific provision of the insurance contract (the policy, the document setting forth the benefits terms and exclusions). What I need to know is how the insurance contract somehow allows the insurer to deny coverage because the long term effects of ADRs are unknown.

Does the policy indicate that the lack of long term clincal data renders ADR experimental and/or investigational, and therefore uncovered or excluded?

Does your contract contain a provision that states that even if a service or device is investigational or experimental, it is nevertheless covered if it is deemed medically necessary? If so then you need to make an end run around the experimental/investgational hurdle by demonstrating Medical Necessity as that term is used in the policy.

Look at your policy and post the provisions here.

Regards
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  #8  
Old 02-08-2009, 11:41 PM
gclc1457 gclc1457 is offline
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Join Date: Oct 2008
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Default

Robert g,
thanks for responding. After reviewing my member handbook the only policy only states;

" expenses and associated expenses incurred for services and supplies for experimental, investigational, or unproven services, treatments, devices and pharmacological regimens, except for services which are otherwise experimental, investigational, or unproven that are deemed to be, in the company's judgement , covered transplant services. The fact that a experimental, investigational, or unproven service, treatment, device, and pharmacological regimen, is the only available treatment for a particular condition will not result in coverage if the procedure is considered to be experimental, investigational or unproven in the treatment of that particular condition."

there are no definitions of an unproven service, or are thier any provisions/exclusions that state a denial of coverage do to tha lack of long term evidence.

I am not the past at understanding the terminology they use in their member handbook, so if you can give me any advice i would really appreciate it .
Thanks so much gary
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  #9  
Old 02-09-2009, 10:16 PM
Robert G Robert G is offline
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Angry Investigational/experimental and Med Necessity

You need to get the policy or the document that describes what is -- and what is not -- covered. Ask the insurer to send it to you if need be.

Find that document and cut out the definitions of medically necessary and the definition of investigational/experimental. Paste them in a post.

I do not want to get your hopes up.

I am new to this. I can't believe that they insist that people get cadaver bones inserted in their necks. They screw on a titanium plate and they're proud of themselves!!! It's 2009.
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  #10  
Old 02-10-2009, 04:11 PM
gclc1457 gclc1457 is offline
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Unfortunatly, this information is something that United Healthcare does't want to give up so easily. I have requested both verbally and in writing the definition of the terms. Over the phone, you are transferred numerous times and told by a representative " let me transfer you to a department that can help you with that". After going through your story with numerous individuals, someone will finally come on and tell you that they only takes requests in that department in writing. Well that's another run around. I have sent letters
to two addresses and still have not received any response. I basically have come to the conclusion that ADR surgery is proven, is not investigational or experimantal, and United Healthcare just doesn't want to pay for it.They pretend as if there is a concern for our well being. It's approved , now let us get the treatment we need. They are just jerking people around from what they really should be covered for. I honestly can say I go to bed at night and wish that the individuals who make these determinations would feel what we feel for 1 week. We all would get approved!!
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