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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 02-08-2015, 04:39 PM
Iron Iron is offline
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Join Date: May 2014
Posts: 13
Default Insurance reimbursement

After almost a year and half of researching to figure out what was wrong with me and finding the best way to fix it, I am 99% sure I will be seeing Dr. Clavel very soon for a 3 level Cervical ADR.
I have researched this forum deeply trying to get the best answer just to remain confused as to the correct procedure and order of achieving a Reimbusement from my Insurance Company.
I have Blue Cross
Here is the question:
1. I have read people just going ahead and having the surgery, then sending the surgery info in to Blue Cross for reimbursement.
2. I have read also that people have gone the old preapproval route, sending their information in before.

I have already been through the appeals process for a one level all the way to the external review level, where I backed out because I have a multiple level problem.
Any assistance, guidance or oppinions will be soooo appreciated.
Thank you
__________________
Body Builder/Trainer
C5 Radiculopathy- with only major weakness in right bicep and deltoid, no pain. Unacceptable
Insurance denial of ADR
Grade 2+ spondylolesthesis at L5/S1 (I can deal with the pain as long as I am active)
May 8 2015----3 Level Cervical ADR @ C4-C5-C6
With Dr. Clavel
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  #2  
Old 02-09-2015, 08:40 AM
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LauraB LauraB is offline
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Join Date: Jul 2013
Posts: 175
Default

Hello Iron,

I was one of the lucky ones who DID get reimbursement from BCBS. I did not get preapproval from my insurance because they don't like the idea that you will leave the states (in my case) to seek healthcare anywhere else; especially a multi-level which was not FDA approved here. I could not have ADR in 2013 due to the multi-level/adjacent to a fusion issue. My only choice was to choose a surgeon elsewhere; otherwise endure multi-level fusion and a restricted lifestyle.
I did go ahead with the surgery anticipating that it would be an out of pocket expense - and yes....I went through my savings, borrowed some money, and sadly sold off some personal possessions. However, my happy thought through all of this was that I would get my life back and enjoy it (priceless!)

My BCBS is through a Chicago Union. I collected all receipts which included a detailed financial statement (in euros and US $) from the surgeon, hospital, and rehab center. I also requested a statement of diagnosis from my surgeon with his surgical notes and opinions. I submitted everything to the BCBS Worldwide network (part of my plan), but they didn't know what to do with it (???) I resubmitted everything directly to our contracted carrier's office. They submitted everything and it took almost a year from the date of surgery to the date I received my check. They covered everything - 100%. How could they not? My actual surgery was a pittance charge for what would have been charged for the surgical intervention here in the states, plus I have a more positive outcome that would not require additional surgery in the future....Saving THEM money! I made sure that I included a letter outlining all of the pre surgical requirements that needed to be fulfilled (therapies, injections, and any other non invasive interventions).

All non-surgical/non-insurance related expenses became a medical tax deduction. My transportation, additional hotel charges, rental car, etc. was submitted and I was able to "eek" back a healthier return too.

I believe persistance is the key with dealing with insurance companies. All too many times they deny claims for absurd reasons - or they made an error. Many people don't bother to question the denial or they make a phone call, but don't get the response they want. I DO! I believe it takes at least 3 phone calls to clear up one little error. Do not give up - perseverance is the key to success. My submission to BCBS was at least 3-4" thick of paperwork - I think I may have scared them away (someone has to read it all).

Good luck to you.
LauraB
__________________
2006 C 5/6 discectomy and fusion
2008 Automobile Accident
C3/4 leftward bulging of intervertebral disc mild narrowing of left lateral recess
C4/5 central and rightward bulging of disc and osteophyte causing mild right neural foramen stenosis narrowing and right lateral recess narrowing
C6/7 Central disc bulging and osteophyte and hypertrophy of ligamentum flavum canal stenosis and narrowing of bilateral neural foramina
Sept 9, 2013 Scheduled with Dr. Bierstedt C4/5 & C6/7 M6
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  #3  
Old 02-09-2015, 09:24 PM
Jerry5 Jerry5 is offline
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Join Date: May 2013
Posts: 363
Default File and Appeal

File for reimbursement, they will haggle and not want to pay, but APPEAL, if they do not the first time.

Make sure you give a detailed history and tell them that this was NOT elective.

Did get some reimbursement.

But I had to fight, call and APPEAL.

This is ALL the more reason for 100% REPEAL of this Monstrosity, they call the ACA.
TORT Reform and 50 state access for ALL insurance.

Best of luck.
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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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  #4  
Old 07-08-2015, 11:31 AM
benihanna benihanna is offline
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Join Date: Feb 2015
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Hi Laura, i hope u are doing well and living pain free. Im in the middle of an appeal for hybrid coverage here in the states even though i dont really want that. Im wondering how you did this. Were u in the appeals process? Did u talk to them first and try to get a reimbursement agreement before u went over there. Im thinking of trying to convince insurance to pay for me to go over there and save them money.
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36 year old male ddd s1-L5-4-3
Life long abuse and neglect, 2013 Discectomy semi-successful 2015 Steroid shots dont work anymore so i cant work
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  #5  
Old 07-08-2015, 11:43 AM
benihanna benihanna is offline
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Default

Also, was it "blue card world wide" i have bcbs of nc with the blue card world wide coverage.
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36 year old male ddd s1-L5-4-3
Life long abuse and neglect, 2013 Discectomy semi-successful 2015 Steroid shots dont work anymore so i cant work
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  #6  
Old 07-08-2015, 12:12 PM
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Cynlite Cynlite is offline
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Posts: 666
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I haven't seen Laura around since she posted on my thread. Take a look at her two posts here: https://www.adrsupport.org/forums/f6...tml#post109793

If these don't answer your questions, I suggest you send her a PM.

Wishing you wellness.
__________________
2006: epidural shots did nothing; 2 surgeons recommended 2 level fusion, I declined.
2007 - 2010 4 foraminotomy and cord decompression cervical surgeries and 2 endoscopic discectomy T7-T8 surgeries; total 6 with Dr. Jho (Pittsburgh,PA) My C6/C7 autofused around 2009.
2013 - 2015: epidurals 3 times (again did nothing) and 4 Radiofrequency ablation (or RFA) procedures.
2016 more RFAs, hit the 10 year mark of this insanity and pain, 3 level M6-C ADR with Dr. Clavel May 19, 2016
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  #7  
Old 08-09-2015, 08:36 AM
Jerry5 Jerry5 is offline
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Join Date: May 2013
Posts: 363
Default Document EVERYTHING

...and go straight to them, BCBS will reimburse.
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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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  #8  
Old 08-10-2015, 09:29 PM
Cheryl0331 Cheryl0331 is offline
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Join Date: Dec 2010
Posts: 890
Default what she said

I agree with Laura B.
__________________
54 yr old female 5'7" 147 lbs. non-smoker conservative treatments failed
2007 fusion @ C4-6 peek cages, failed due to long term use of cox-2 inhibitor
2008 revised C4-6 donor bone, plate & screws
2009 fusion with Roi-C @ C3-4
2015 MRI & CT mjr ddd @ C6-7, segmental kyphosis at C7-T1, 2-level M6-C prosthesis by Dr. Clavel Barcelona Spain
2019 H.O. formed behind M6-C @ C6-7 left nerve rt & in spinal canal.
2020 Revision C6-7 to a CP-ESP prosthesis by Dr. Schmitz Dusseldorf Germany
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  #9  
Old 08-17-2015, 07:20 PM
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LauraB LauraB is offline
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Join Date: Jul 2013
Posts: 175
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Sorry guys. I haven't been around too much lately only due to a job change and dealing with my mom's cancer.

I went with the BCBS Worldwide and found myself moving in circles. I eventually contacted local office "Union," and explained the situation. I copied and resent my file - I think the size of it scared them into submission. They took it over and paid.

From my perspective, if I was traveling and had this issue, I would be treated overseas using the "best practice" available. In Germany, they have been performing this surgery, successfully, for over 20+ years. That doesn't seem like "exploratory" or "experimental" procedures. This is what I made clear in my explanation of the diagnosis and treatment. It also was important to show that you have exhausted all forms of "non-invasive" pre-surgical protocol procedures prior to surgery; being your last resort. I included a timeline history of cervical injections, therapies, and diagnostic testing.
__________________
2006 C 5/6 discectomy and fusion
2008 Automobile Accident
C3/4 leftward bulging of intervertebral disc mild narrowing of left lateral recess
C4/5 central and rightward bulging of disc and osteophyte causing mild right neural foramen stenosis narrowing and right lateral recess narrowing
C6/7 Central disc bulging and osteophyte and hypertrophy of ligamentum flavum canal stenosis and narrowing of bilateral neural foramina
Sept 9, 2013 Scheduled with Dr. Bierstedt C4/5 & C6/7 M6
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  #10  
Old 08-17-2015, 08:14 PM
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Cynlite Cynlite is offline
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Join Date: Mar 2015
Posts: 666
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Laura, I'm so sorry to hear about your Mom's cancer. I wish you both wellness and hope for her full recovery. I know it's difficult because I helped both my parents through their illnesses and end of lives. I'm so sorry you and your family are facing these challenges. Sending prayers.
__________________
2006: epidural shots did nothing; 2 surgeons recommended 2 level fusion, I declined.
2007 - 2010 4 foraminotomy and cord decompression cervical surgeries and 2 endoscopic discectomy T7-T8 surgeries; total 6 with Dr. Jho (Pittsburgh,PA) My C6/C7 autofused around 2009.
2013 - 2015: epidurals 3 times (again did nothing) and 4 Radiofrequency ablation (or RFA) procedures.
2016 more RFAs, hit the 10 year mark of this insanity and pain, 3 level M6-C ADR with Dr. Clavel May 19, 2016
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