Need help with insurance precedent!

[timmyat]

Hi Everyone!

I am so glad I found this forum. I came here looking for advice on how to fight a denial for ADR and I have found it to be a very helpful resource!

I am currently preparing an appeal letter for my L5-S1 ADR denial and after reading many threads here, realize I have a large fight on my hands. I have been able to gather a lot of research on how to prove my case but I am missing the most important part, insurance precedent! I feel without this I have no chance for approval.

What is the best approach to getting this information? I am looking for approvals for both lumbar and cervical ADR and any insurance company will do. I see others asking for name, procedure, ins. co., and date. Is this sufficient information to prove precedent? I wish there was some sort of ongoing list that anyone could reference but I understand that privacy concerns might prevent that.

Any advice is much appreciated. Thanks for your help!

[NJ Gene]

You might want to send a PM to GinaMarie1221 . She successfully won an appeal with BC/BS and had surgery with Dr. Jack Zigler of the Texas Back Institute in mid-March.

[timmyat]

Originally Posted by NJ Gene

You might want to send a PM to GinaMarie1221 . She successfully won an appeal with BC/BS and had surgery with Dr. Jack Zigler of the Texas Back Institute in mid-March.

Thank you! I also have BCBS so this might be a big help!!

[Running11]

I just got approval from BC/BS of Ohio at the external level I fought like a bulldog .
I needed a two level and they approved one. They denied the other one because said it wasn't medical necessary. My doctor said the one they approved was better than the one they denied.

I have 6 documented cases they paid for. PM me if you still need help. I would love to provide you with that information. I hate Bull Crap Bull ****. (BC/BS). However, these cases didn't help.

They based my approval on an EMG study that showed a nerve root blocked. you need as many opinions as you can gather along with letters and every test you can provide them with.

[Running11]

CASES LISTED BELOW THAT BCBS HAVE PAID FOR
CERVICAL OR LUMBAR ARTIFICIAL DISC REPLACEMENT
ARTHROPLASTY



1.) Disc: Cervical
State: North Carolina
Payer/Administrator: BCBS of North Carolina
Stage of Approval: Independent External Review

Notes: According the reviewing physician, “ It is not reasonable to delineate cervical disc replacement as experimental or investigational. Numerous publications attesting to its success long term and short term and it has been FDA approved….


2.) Disc: Cervical
State: North Carolina
Payer/Administrator: BCBS of North Carolina
Stage of Approval: 2nd level of appeal

Notes: This case was approved as a result of the internal independent review process where 2 board Certified Neurological surgeons reviewed the appeal
And each determined the treatment was medically necessary. The denial being overturned at the 2nd level of appeal instead of through external review process sets a powerful precedent for future approvals.


3.) Disc: Cervical
State: Massachusetts
Payer/Administrator: BCBS of Massachusetts
Stage of Approval: Independent External Review

Notes: According to the reviewer: “Cervical arthroplasty is in no way experimental or investigational. .I would yield to the discretion of the individual surgeon as far as arthroplasty versus arthrodesis. Either one is acceptable and meets the standard of care for this problem.”


4.) Disc: Cervical
State: Florida
Payer/Administrator: EMPIRE BCBS/ Carmax Inc.

Notes: After receiving a denial by Empire BCBS, appealed directly to the plan administrator, CarMax, who overturned the denial in short, order.






5.) Disc: Lumbar
State: Illinois
Payer/Administrator: Anthem BCBS of Indianapolis
Stage of Approval: Independent External Review

Notes: The independent reviewing physician stated,” The current literature would suggest that this patient is a candidate for and artificial disc replacement”

6.) Disc: Cervical
State: Arkansas
Payer/ Administrator: Empire BCBS
Stage of approval: 1st level of appeal
NOTES: Empire BCBS rendered a decision and overturned their previous denial within 30 days following the review of this matter by a third party physician reviewer (board certified physician with a specialty in Neurosurgery) who determined that cervical arthoplasty was medically necessary.

7.) me (please don't put my name)
Disc: Cervical
State: Ohio ( I live in Ca, long story)
Payer: Anthem Blue Cross Blue Shield
Stage of Approval: External review





I hope this helps your case. You can't put names and doctors of patients because of the HIPPA laws. I sent BC/BS 63 pages of documents. I called them every other day about my case. They even had one person in charge of my case because I was a PIA.

My precertification failed because they said it was not medically necessary and investigational… so I sent them records of all 12 doctors who have treated me along with 2 MRI's , XRays, Discograms, CT scan with injection die, 2 full and complete EMG/NG nerve tests. Yep, all 63 pages! Please don't leave it up to your doctors to send all your records. They can't because they are exhausted fighting insurance companies. Send it all yourself.

First appeal was denied because it was investigational so I sent them as many studies that I could that said it wasn't along with the cases above.

They denied granting me my second appeal . How? They ignored my faxes emails and certified latters. They said my husband said not to put it in until they answered our question as to why a foot doctor denied my surgery? It was a mistake on their part . I found the doctors name on my denial letter and called the doctor for an appointment and they refused to see me because he doesn't treat spinal patients.

Then, I sent them another nasty fax saying they were denying me my House Bill right 216 and they needed to grant me an external appeal immediately. They called me within 30 mins of receiving my fax and expiated my external appeal.

DO NOT UNDER ANY CIRCUMSTANCES GIVE UP. My external was orginally denied and they somehow reconsidered. They won't discuss why or what happened with me at all. I am waiting to hear from my surgeon as to when we will schedule it. I feel vindicated and in 6 months they will hear from me again. I will put in for the level that was denied. I will not give up and neither should you !

They will make you jump through hoops, ignore you ,deny you and refuse to answer any and all your questions. Don't fold , please feel free to PM me with any questions. Good luck. You can do this. They want you to get tired, frustrated, give up, go away or die. They will be happy with any of those.

P.S. On my external review it said at, " this procedure is not investigational/experimental! My doctor wants to frame it. If we stick together we can make a difference!
Tammi

Oh and you can add me for your seventh!

[calvin12]

Noticing that there are no approvals in CA. One of the surgeons I saw, said that BC has approved them in other states but not CA. I maybe in the same boat when I finally find someone here to do the procedure.

[Running11]

That shouldn't matter. I live in California but my husbands company's headquarters are in Ohio. A precedent is a precedent . They paid for it before so they have to again. Just make sure you go through all you appeals

Good luck. Even my doctors said I wouldn't get an approval. I didn't listen. Keep plugging along.

Tammi

[NJ Gene]

Tammi,

Do you have a date set?

Gene

[timmyat]

Originally Posted by Running11

I just got approval from BC/BS of Ohio at the external level I fought like a bulldog .
I needed a two level and they approved one. They denied the other one because said it wasn't medical necessary. My doctor said the one they approved was better than the one they denied.

I have 6 documented cases they paid for. PM me if you still need help. I would love to provide you with that information. I hate Bull Crap Bull ****. (BC/BS). However, these cases didn't help.

They based my approval on an EMG study that showed a nerve root blocked. you need as many opinions as you can gather along with letters and every test you can provide them with.

Tammi, congrats on getting your approval!!

The info you provided will be a HUGE help for me!! I am glad to see that names aren't needed to prove precedent and I will definitely leave your name out. If I have any other questions I'll PM you. Thank you again!!

[Running11]

Gene,

I don't have a date for ADR surgery at C 5-6 yet. My surgeon is waiting for pre-op authorization in writing from BC/BS. I agree that my doctor should wait for that ,but having gone through an external reviewer (insurance hell) for this surgery I don't understand why BC/BS didn't authorize that already. BC/BS loves to wear you down.

Tammi