Appeal sent by email

[Harrison]

My appeal process was unique but eventually successful. I was polite, tenacious and made way too many phone calls. I don't think this will help much, as the insurance company's mantra presently is to say "NO." Find or budget the energy to be lucid, be creative (like Nichole!) and keep good records. Some people are successful!
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May 31, 2004

BCBSMA
401 Landmark Drive
Boston, MA 02215
Attn: (name withheld)

Dear Dr. Beancounter,

I do not know if you are accustomed to communicating directly with BCBS subscribers, but I have performed enough telephone research to know that you are the right executive at BCBS to address my questions. I have worked diligently seeking coverage for my needed artificial disc procedure (ADR) and made the requisite appeals following the appropriate protocol. Out of sheer despair and utter desperation, I am seeking your assistance in this urgent matter.

After speaking with many patients from around the world about their lumbar fusions and learning of their unfortunate outcomes, I canceled my ALIF procedure in April 2004. Concurrently, I did extensive online research and spoke with more than a dozen people who had ADR procedures (both one and two-level), who are very satisfied with their outcomes. I am now convinced that ADR is the best available option for me.

While I grapple with the physiological and emotional aspects of my worsening condition (L5-S1 disc is completely degenerated), I await ADR surgery at New England Baptist Hospital on June 24. However, the cost associated with this procedure is staggering; it is at least $35,000. Therefore, with these ugly circumstances as a backdrop, I am hoping you can help resolve my quandaries regarding ADR insurance coverage:

1. Pending ADR Policy Changes. The FDA Orthopedic and Rehabilitation Devices Panel of the Medical Devices Advisory Committee meeting on June 2 will discuss (and likely recommend) a pre-market approval application for the Depuy (Charit�) artificial disc. Will a positive outcome of this meeting allow your company to provide coverage to me in time for my ADR procedure?

2. Alternative Surgical Institutions. Many people have traveled abroad (e.g. Munich, Vienna) to receive the services of the world�s most experienced ADR surgeons, while paying approximately 40% less than American hospitals. Moreover, many of these people have been reimbursed by BCBS for these overseas surgeries. Would I stand a greater chance of reimbursement if I sought ADR care from a European clinic?

3. Dangerous Waiting Games. I have limited mobility and a marginalized quality of life. Yet, if I cannot come up with the money to have ADR locally (or fear losing my house as collateral in the event of unforeseen medical circumstances) how long must I wait before BCBS updates the ADR insurance policy?

I am grateful for the consideration you have given me by reading this letter. As you now know, I am in a complicated situation and would benefit by your insights. Accordingly, I will be in your debt if you would advise me of my current and near-term options.

Sincerely,