Florida Blue (BCBS Florida) Approval!

[GravyBaby]

Hi all,

I was shocked to find out last week that BCBS of Flordia, known locally as Florida Blue, approved my lumbar disc replacement surgery procedure (L5-S1) in full (minus my deductable) with Dr. Rolando Garcia of the Orthopedic Care Center of Aventura Hospital in Aventura, Florida, after a short (5 day) medical review.

Dr. Garcia informed me during our second meeting, around the end of August of this year, that he heard Florida Blue was on the verge of adopting lumbar ADR into their standard procedure approval. On researching on my own, I found that a reported 62% of nationwide insurance companies are now covering the procedure, with more joining the ranks by the end of the year.

I crossed my fingers and hoped and prayed and really lucked out. It took one week (5 business days) to get the approval. Even more lucky was that we did not have to submit an appeal. I thank Dr. Garcia's staff for preparing the submission to our insurance with great expertise.

It is possible that my condition had something to do with the quick approval. I have retrolisthesis, a form of spondylolisthesis, which has progressively incapacitated me over the past year. In addition, the new strict opiod laws forced me into the emergency room three times the week prior to our insurance submission. Those factors may or may not have played a role in the quick approval.

I would highly recommend Dr. Garcia for anyone in the US looking to get their ADR surgery approved through insurance. His staff is ready to help and he will answer any questions you may have.

A little info about Dr. Garcia: He was co-developer in the latest FDA-approved artificial lumbar disc, the Activ-L. He was part in the FDA trials for the Activ-L. He has performed hundreds of successful ADR surgeries with the charité, prodisc and Activ-L devices over the past 18 years.

Good luck to everyone in their quest for insurance coverage!

[GravyBaby]

BIG UPDATE!

I found out today that my insurance company REVERSED their decision on my surgery and reversed their payments to my physicians and hospital for my surgery weeks after I had it done. I only found out because I went to refill my prescription and they asked me to pay. I had already hit my out of pocket maximum and deductible with the surgery co-pay and was enjoying not having to pay any more for my medical care.

I come to find out that my co-pay for the surgery was removed from my insurance account entirely. I am now having to pay for doctors visits and medication out of pocket even though I already paid a bundle to my doctors office for the procedure. Currently in the process of working this out with my insurance company and doctors office.

[GravyBaby]

Small update to my insurance post-prior authorization denial:

My surgeon's office submitted my info to Aesculap, the developer of my artificial disc, and they have taken my case up to go through the appeal process on my behalf.

[Cheryl0331]

Why would an insurance company want to pay for a fusion that will lead to more surgery, when an ADR will save them money in the long run?!!!
It is absolutely absurd!

[Cheryl0331]

If an insurance company approved you, then denies you after the fact; Ibwould hold them liable became you might have not proceeded and have that expense all on your shoulders.

[GravyBaby]

Hi Cheryl,

So I did call the state insurance board shortly after my initial denial and they informed me that it is legal for them to do that. Now, is it right? Of course not! But they do it anyway.

In any case, I forgot to update in the winter, BCBS of Florida or Florida Blue DID end up paying for my surgery.

It took a year and a half of appeals, but they finally paid on the final step of external appeal.

Thank goodness I did not get caught with the bill. I was prepared to file for bankruptcy.

[Cheryl0331]

Well alls well that ends well, but the stress of that appeal was something you shouldn't have had to go through.