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The Big File All issues not easily categorized in the above forums are here. Comments on general health, diet, "getting comfortable," and more are here.


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  #1  
Old 06-27-2005, 06:31 PM
inflexable inflexable is offline
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I have 5 days to meet the deadline to appeal (2nd) to BC/BS of western pa. The problems is I have nothing more to add. I gave it my all in the 1st appeal. I had several people read it and the only way one could deny was to ignore the stated facts. I have been stewing since I got the reply to my 1st appeal DENIED! and the reason given was the same "investigational" only because they say so of course.

Im perplexed, if they are dead set on not looking at the facts what else can I say?

actually considering the fusion, don't have the fight in me much more. The pain is getting worst. My doc now has me on restrictions and I may need to use up all my disability before I even have an opperation and would not have any left at that point.

Before this, I would not have believed that insurance companys can do this to people. unbelievable.

any help would be appreciated.
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  #2  
Old 06-27-2005, 07:15 PM
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Harrison Harrison is offline
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Pls search using the search button; you can search any and all forums. When you find people that have threads of your concern, feel free to send emails or PM
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  #3  
Old 06-28-2005, 12:36 AM
sahuaro sahuaro is offline
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I am so sorry your decision for your health has to be based on your insurance company. You may want to check out:
http://www.bcbs.com/tec/vol20/20_01.html
It is the technical report published in 4/05 on which BC/BS is apparently basing its denials. Other members with much more knowledge than I have might be able to help you formulate a response.
I hope this helps.
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2001 MVA; C5-C6 disk extruded
ongoing physical therapy, exercise and massage
ESI's, oral prednisone, trigger point injections
foraminal and central stenosis C5/C6 and c6/C7
2007 EMG/nerve conduction shows pattern of chronic radiculopathy
January, 2008: Prestige ST Artificial Disk Replacement, C5/6
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  #4  
Old 06-28-2005, 04:08 PM
sfmcfar sfmcfar is offline
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The only suggestion I have, if you haven't done it before, is to attempt to refute your health plan's definition of "experimental." If you can show that ADR does not meet their own definition of experimental, you might have a chance. That assumes, of course, that they read your appeal.
My insurance (MD-IPA) didn't even bother reading mine - their response had absolutely nothing to do with the basis of my appeal.
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  #5  
Old 06-29-2005, 10:09 AM
BRENDAWY BRENDAWY is offline
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I READ IN A POST SOMEWHER IN HERE THAT BC/BS HAD PAID IN PA JUST RECENTLY. I WILL LOKK FOR IT. I ALSO SAW THEY PAID IN DE, NJ, NY. HOW CAN IT BE EXPERIMENTAL WHEN YOU CROSS STATE LINES. BRENDAWY
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  #6  
Old 06-29-2005, 12:17 PM
kt kt is offline
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I have BC/BS of PA, we received our second denial, the first excuse was investigational etc., I found it interesting that the second excuse was "not medically necessary", We are now appealing to our HR, but if ANYONE has had BC/BS of PA pay please let us know.
KT
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  #7  
Old 06-29-2005, 06:45 PM
Rein Rein is offline
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The above is a real good example of why we need to be thinking about what and how we post. Try searching for PA and see what you get! On the other hand, searching for Pennsylvania, unfortunately, does little good because no posts occur with both Pennsylvania and Blue Cross Blue Shield or BCBS. I came up with about 36 posts that *might* be the answer we're looking for, but not one is labelled obviously so the only alternative is wading through *all* of them until I stumble on the one for which we're looking! Oi!

What I'm driving at is this: Think of the value of your posts not only for yourself at this moment, but in terms of research value for the future. If you really think about what you're posting and how you write it, then members searching in the future will be able to easily retrieve the information you posted and derive some benefit from it. Acronyms are valuable as shortcuts when everyone (including the search engine) knows and recognizes them, but when they are only known to the author of a post then they only serve to confuse (and the information they represent is only valuable for the short time that the thread is active). (Hey, I come from Massachusetts. You think I like writing *that* out every time?!!) ;-)

While I'm on the subject of posting quality, I'd like to gently request that posters remember that accepted Internet standards recognize ALL CAPS as the equivalent of SHOUTING and ought only to be used for that purpose (but not here, as we *never* shout at our neighbors here!).
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03/09/26 - Ruptured L5-S1.

Years of pain, discectomy, research into anatomy, hardware, clinical trials, facilities, surgeons, techniques, insurance. Attempts at ProDisc, Activ-L trials. Now, low bone density. D'oh!!!

At 61 years, no longer qualifying for trials due to my age (chronological, not physical or mental).

2009 - Working on improving bone density or getting rich so I can go to Germany, where medicine and insurance have gone beyond the Stone Age.
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  #8  
Old 06-29-2005, 09:58 PM
Danielle Shawgo Danielle Shawgo is offline
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I know that BCBS is paying in New Jersey because I found an article about it on the Charite website. I asked my insurance (I also have BCBS) why it would be approved for one section of a business and not another and they didn't have an answer. I am trying to get my insurance to pay right now. I will let you know how it works out.
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  #9  
Old 06-30-2005, 10:48 AM
Rein Rein is offline
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Another question whose answer is already posted on this forum...

This is what I found out after researching and reading within this forum and emailing members over a period of a couple months:

Insurance companies are *not* organized on a national basis (for the most part). They are set up independently on a localized basis which can be state by state or within multi-state regions and sometimes even more fragmented than that. They are also administered differently, depending on who is being insured or how large the ensured group is, and this varying administration means that different entities sometimes make the final decisions on appeals. Some are self-funded and separately administered and some are not. The upshot of these disparities is that what a BCBS in Washington State does has practical bearing (and sets no recognized precedent) with what a BCBS in another state does. They are not connected in any way which is subject currently to overall national legal remedy and they are certainly not connected in an financial way, other than that they share a common name and some varying franchise benefits from the parent entity, who is not liable to the insured (check your statements of policies or brochures - BCBS is always careful to put that wording right on the cover or first page of every brochure).

This is the sad condition of our current national insurance legislation and until something is done (on a national level) to force insurers to: 1 - pay for all FDA approved procedures, and 2- accept a single, unified description of policies and responsibilites across state and separate company lines, we here at the ADR Support Forum (and all other residents of this country who are medically insured) are left with wrangling with them on a company by company basis.

As this group become larger in numbers and more members post their successes with specific state-located companies I hope insurance will become much less of an obstacle for those seeking ADR. This is why it is vitally important for every member who has finally obtained ADR through insurance to post their details. As each member gets compensation for ADR from their individual insurer and posts specifics about how they worded their pre-certs and appeals, the next member down the line from the same state and insurer will be able to reference the successful member's information and short circuit the insurance industry's zeal for denial.

On a specific note to Danielle: If BCBS Washington State told you they didn't have an answer then they were lying or you talked to the wrong person!

Here's the link Danielle was referring to:

http://www.depuyspine.com/about/about.press.040605.asp

The title, if I were to post the article in our Articles Library, would be "Blue Cross Blue Shield (BCBS) New Jersey Approves Payment for Charite Artificial Disc".
__________________
03/09/26 - Ruptured L5-S1.

Years of pain, discectomy, research into anatomy, hardware, clinical trials, facilities, surgeons, techniques, insurance. Attempts at ProDisc, Activ-L trials. Now, low bone density. D'oh!!!

At 61 years, no longer qualifying for trials due to my age (chronological, not physical or mental).

2009 - Working on improving bone density or getting rich so I can go to Germany, where medicine and insurance have gone beyond the Stone Age.
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  #10  
Old 06-30-2005, 06:52 PM
sahuaro sahuaro is offline
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I endorse your suggestion that the insurance information be organized. BCBS is certainly a state-by-state insurance but as you indicate, there are some companies which are not. Do you know which companies are not? Of course, there will be variations also depending on the particular contract.
__________________
2001 MVA; C5-C6 disk extruded
ongoing physical therapy, exercise and massage
ESI's, oral prednisone, trigger point injections
foraminal and central stenosis C5/C6 and c6/C7
2007 EMG/nerve conduction shows pattern of chronic radiculopathy
January, 2008: Prestige ST Artificial Disk Replacement, C5/6
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