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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
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Well, the saga continues. My appeal was denied by MAMSI, again using the "experimental" label. I haven't seen their formal response yet, but I received a "courtesy" call from their appeal "auditor" informing me of the decision. Here's an entertaining recap of the conversation:
Me: "Did you personally see my appeal?" She: "Yes. My job is to ensure that MAMSI meets the guidelines for federal employees in their appeal process." Me: "If that's your job, then please explain to me why MAMSI is choosing to violate the Federal Employee Health Benefits Plan regulations by labeling FDA-approved procedures as experimental, which was the basis for my appeal." She: "I can't answer that. I'm not a medical person." Me: "I'm not asking you a medical question. If you *really* did read my appeal, you would have read the regulation, which was included in the appeal. I'm simply asking you why MAMSI believes they don't have to comply with the regulations." She: "You don't understand. I have no medical training." Me: Sigh...... So, the next step is to appeal to the US Office of Personnel Management, which has given every indication that they'll reverse the decision if sufficient evidence is shown that I meet the FDA indications for use. Fortunately, my back is in a fairly "quiet" period so I can probably wait the 60 days for OPM to respond to the appeal. Onward...
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Stan L5-S1 DDD and herniation |
#2
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Sorry Stan.
Keep up the fight!
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"Harrison" - info (at) adrsupport.org Fell on my ***winter 2003, Canceled fusion April 6 2004 Reborn June 25th, 2004, L5-S1 ADR Charite in Boston Founder & moderator of ADRSupport - 2004 Founder Arthroplasty Patient Foundation a 501(c)(3) - 2006 Creator & producer, Why Am I Still Sick? - 2012 Donate www.arthropatient.org/about/donate |
#3
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Hi Stan, I'm in the same boat. Same song, different insurance. I thought the doctor's decision ruled. I guess "Non-Medical" insurance company employees know better than the doctors. What can OPM do?
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#4
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Thanks to all of you for responding to me today about the insurance question. At least I don't feel like I am out fighting on my own now.
Becky
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Becky |
#5
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Stan
Do you think you could get a copy of those "guidelines"? It's very possible the person who called you up was only reviewing your appeals process for things like number of days from the time the appeal was submitted until it was answered, which would certainly explain why that person had no medical training and needed none.
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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. |
#6
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Rein,
You may be right. She was definitely not hitting on all cylinders. The thing that *really* gets me is that MAMSI isn't playing by the rules. Most insurance carriers can decide for themselves what's "experimental" which is why so many people on this board are getting screwed. The exception is that if you're covered under a Federal Employee Health Plan (as I am), the carrier is not allowed to label anything that's FDA approved as "experimental." And when I try to point this out to MAMSI, they act like they don't even hear me. I'm reminded of the "Far Side" cartoon called "What dogs hear" - I think that MAMSI hears "blah blah blah blah artificial disc blah blah blah". My hope is that my appeal to the US OPM will resault in MAMSI having to pay a fine for violating the regulations.
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Stan L5-S1 DDD and herniation |
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