ADR Surgery Done, Waiting for Denial.

[Jen93312]

Uggh! My insurance will change in a few weeks to BCBS of Texas. They have a buy-up plan & I'm hoping the international option is included. L

[kimmers]

Originally Posted by VegasGuy13

Thanks for the information. I would hope there is a reference out there somewhere that alludes to Federal employees being approved for a procedure if the FDA has approved it.

Vegasguy,

I looked up some information I have in my last appeal to BC. It was not BC who paid but the person (I think it was treefrog) sent me a copy of the approval letter from her insurance, Coventry Health Care, which I put in my appeal.
She was a federal employee and this is part of what the letter says:

Our Medical Director has reviewed the information submitted to include, but not limited to, letter of medical necessity, cost estimate of insurance, patient pre-evaluation questionnaire, and Plan language. The predetermination request was elevated to our Medical Director, Floyd Shewmake, MD, for consideration. Dr. S reviewed the prior determination made by our Medical Director Debra Esser, MD, and overturned her decision. He states that the Federal Employees Health Benefits (FEHB) Plan cannot deny the artificial disc as experimental/investigational if it has been approved by the FDA (Food and Drug Administration). Therefore, we are able to approve the artificial disc placement surgery as medically necessary under the Plan's contract of benefits.

this letter was dated April 23, 2009 and was to Dr. Rudolph Bertagnoli in Bogen Germany.

This is why I do not believe that an insurance company can deny any federal employee anything that is FDA approved. So keep trying, chances are you will succeed.
As for material for my appeal, I found it difficult to receive actual approval letters as people worry about the insurance companies' power to take back an approval or money. With a lot of digging, I actually got a lot of information. BTW, the lady who gave me this letter lives in South Carolina and I am sure, she would probably give you a copy if you find her on here.

Happy hunting,

Kimmers

[kimmers]

Hey Vegas,

I am not completely sure it was treefrog as it has been a few years. If you can get a hold of her, however, she has a lot of info about ADRs and Slackwater does too.

K

[tidebiz]

Originally Posted by VegasGuy13

Thanks for the information. I would hope there is a reference out there somewhere that alludes to Federal employees being approved for a procedure if the FDA has approved it.

VegasGuy - Do you recall what your surgeon charged, and what the surgery center charged, for your 23 hour stay C5-6 arthroplasty? Many thanks,

[2Confused]

Vegas Guy,

BCBS paid for my two level ADR (60%) and I had the surgery overseas. Submit a claim and appeal them if they do not pay. Also, I just read recently that the FDA has now approved 2 level ADR Cervical surgery. That should help you with the claim. Hope you are doing well.

[bwink23]

2Confused.....are you a federal employee?

[VegasGuy13]

I am a retired Federal Employee.

[Running11]

No , I wasn't because BC/ BS is contracted with hospitals to pay only a certain fee . They charge people like you and I a super bill rate. Since , I was approved through the third level of appeals BC/ BS payed their contracted rate. I don't understand his all this works but if your insurance covers you 100 percent based on plan. Everyones plan is different and the amount they are required to pay. Example , meeting deductibles. Just because I didn't have to pay the rest doesn't mean yours will cover it too.

[2Confused]

Originally Posted by bwink23

2Confused.....are you a federal employee?

No I am self Employed, so I have an individual policy through BCBS.

[FranklySir]

2confused,

I too had a 2 level with Dr. Clavel June 5th 2013. I a;leo have BCBS and own a small business in PA. My Ins co is having the first review this coming Friday.
Keep your fingers crossed for me. I did PM you the other day for any help you could provide.

I am hoping to win this round since now i need two level in lumber L34 L45. Not sure how long I can hang on at this point with not getting intervention. cannot even get a flight anyway before Christmas or more to the point afford it at 12500 per ticket.

Any help would be greatly appreciated per my PM.

Frank