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  #11  
Old 03-14-2006, 12:26 PM
go*big*red go*big*red is offline
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So, how do you find out who has reviewed your case dr. wise?

And, what were the denials based on? What UHC has said is that it's still experimental!!!!! So, Charite' people sent a packet to accompany the rest of the stuff to the "independent" review.

There is no question that I need surgery. And, they are more than willing to approve a fusion. Grrrrrrrrrr. I'm almost at the point of buying more time with a second fusion at L4/5 and then in a year or 2 (when the pain becomes unbearable at L3/4) do an ADR at that level. Shouldn't have too much trouble then getting it approved.

That is if this is denied. My other option is perhaps going to the insurance commissioner of Colorado. I have dealt with them with one of our employees vs our group health insurance and the employee won. It was actual payment of claim, though and not preauth. But, that might also be worth a try.

But, I don't like the way my thoughts are running. I want approved. Plain an simple.

Thanks for all the replys. I'll keep you posted. I like the idea of being the first of many.
__________________
Juvenile Discogenic Disease
2 level ACDF C5/6, C6/7
Redo on C6/7
PLIF L5/S1 - hdwr removed when C6/7 revision
PLIF L4/5 & Dynesys L3/4 10/10/06. Looking forward to living again.
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  #12  
Old 03-15-2006, 12:49 AM
Kim Kim is offline
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I called them and requested the information as to the DRs credentials who reviewed my case as it was necessary for me to have that info for my next appeal
They are required to send you by law all of the documents that they use for your review and all the info that you sent them etc. U have to request the records in writing but I got the info on the drs over the phone by the case manager of my appeal.
They didnt like it one bit either and one nurse was a witch and she got reported for it but that is a story for another day.
Call and ask them for the info and ask them for the papers that they used to deny your appeal. You might find it very interesting to see what it says. I got the whole report from the dr etc.
Kim
__________________
Kim
Herniated disc L5/S1 2000 Discectomy 10/2003 Rhizotomy 8/2004 and 3/2005Discogram 11/04 grade 7 tear L5/S1
L4/L5 Grade 5 tear with herniation and stenosis
Evaluated by Dr Blumenthal at TBI
2/2005 ADR 2 level recommended
2 level lumbar fusion
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  #13  
Old 03-15-2006, 07:06 PM
APS APS is offline
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I requested the medical director's curriculum vitae and his credentials in my letter to UHC requesting the docs but conveniently they didn't include anything re the dr.
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Andrea
Grand Junction/Denver, CO

Failed L4-5 diskectomies '93 & '00
ADR originally scheduled 3/9/05; dropped insurance appeal due to new job; new insurance UHC
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  #14  
Old 03-16-2006, 08:53 PM
wbaker68 wbaker68 is offline
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workers comp here in delaware used to be able to call their exams of claimants IME's(indep. medical exams) However, if they write that in letter to claimant or accidently call it that during hearing they can be fined $500. In our statute. Must be called DME now(Defense Medical Exam). No such thing as Independent with worker's comp.

Just my two cents. But in case of healthcare, its possilbe to be independent if your doc and the BCBS doc picked who was doing the review, otherwise, same scenario as comp and its far from independent at all!!!

Sorry, doens't have much to do with topic, but thought might find interesting.

take care, bill
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Spinal Cord Stimulator Implant 6/11/03; Discetomy 12/89; L3-S1(3 level) ADR, August 7th, 2004 by Bertagnoli in Vienna, Austria.

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  #15  
Old 03-16-2006, 09:32 PM
JL JL is offline
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Hi Bill, Independent Medical Exam misnomer is one of the topics I missed in my presentation preparation to CT Labor Committee for tomorrow at the State Capitol. I am bringing your information verbatim to the committee co-chairs. These are the Senators who over see WC here. I have whined and protested my way to the top. I am planning to request a Senatorial Review and Investigation into WC tomorrow. The traditional IME lie and our Voluntary Agreement form, (which states This is not a Final Settlement, which it really is) have to go. So you see, you may not have thought it had something to do with the topic, but it is going to the top tomorrow. Posting Pays. (JL)
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(Bill) 14 yrs L5-S1 pain & tear
Discography 2003 DDD
10 yrs. chiropractic
6-14-05 L4/5 & L5/S1 Prodisc Yale New Haven CT Dr. James Yue
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  #16  
Old 03-17-2006, 06:43 PM
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Eddie_G Eddie_G is offline
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As I posted in another thread, I'm going for my 2nd Independant Medical Exam on Tuesday. This guy is NOT a fossil. He has done a handful of Charite's so I may be seeing the right guy. I'm going to pick his brain about his decision to use Charite and hopefully get him to refer me to a good disc doctor. Liberty Mutual's In-Network WC doctors have very little experience in ADR so I may wind up in court anyway.
I pushed my appointment with Hallett Mathews(East Coast Maverick doc)back until May hoping I'll get approved by then.
James Yue would be a great plan B for me AND for the insurance co. since it may save them some $$$.

For my IMExam, I'm staying in the historic area of Phily which is just a few blocks from the doctor. Me & Sweety are celebrating 1 year and we're taking a mini-vacation (Atlantic City first, then Phily) so it won't be all doctor stuff.
__________________
12/16/03 Work Accident
Herniation and DDD at L4-L5
4/1/05 Discectomy
Epidurals and facet injections
5/15/06 Discogram confirmed L4-L5 DDD also an asymptomatic L5-S1 tear
10/24/06 L4-L5 Prodisc surgery with Dr. Goldstein
CAT scans & X-Rays show ossification
Trigger Point Injections, Medial Branch Blocks, Acupuncture, Weekly Deep Tissue Massage
10/27/08 Discogram (positive L5-S1 tear)
11/25/08 L5-S1 fusion with Dr. Goldstein
FAILED BACK SYNDROME
Liberty Mutual WC
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  #17  
Old 03-23-2006, 06:07 PM
go*big*red go*big*red is offline
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Okay - update.

Spoke with CA Ins. Commissioner's office yesterday.

1) they have to determine jurisdiction.
a. If Pacificare is a trust, then California does not have jurisdiction and I would need to go through Colorado.

2) Pacificare IS NOT a trust, so CA does have jurisdiction.

3) Prove to them that the Charite' is not experimental. That is the reason that PC gave for not approving.
a. I now have a call in to the DuPuy people to get national publicated articles with trial results, etc.

Interesting note: no one is arguing the fact that I need surgery. This guy said that if it were still experimental, that no one would have approved it. I thought, where the )*()& have you been? They've been approving it all over the states.

At the time that we do all of the above, then they send the info and my file to an independent medical examiner. Then, he gives his determination. I asked if they send my file to a pediatrician or what. He said they contract with a group of drs., spine specialists included (dinosaurs?). So....we will see.
__________________
Juvenile Discogenic Disease
2 level ACDF C5/6, C6/7
Redo on C6/7
PLIF L5/S1 - hdwr removed when C6/7 revision
PLIF L4/5 & Dynesys L3/4 10/10/06. Looking forward to living again.
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  #18  
Old 03-24-2006, 06:03 PM
go*big*red go*big*red is offline
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Okay, new news

Because it is not a trust, correction - it will be the jurisdiction of Colorado, not California. That has it's benefits, and drawbacks.

Just waiting to see. Really tired of this! Is that their ploy? To wear us down?
__________________
Juvenile Discogenic Disease
2 level ACDF C5/6, C6/7
Redo on C6/7
PLIF L5/S1 - hdwr removed when C6/7 revision
PLIF L4/5 & Dynesys L3/4 10/10/06. Looking forward to living again.
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  #19  
Old 03-24-2006, 11:41 PM
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Eddie_G Eddie_G is offline
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Posts: 238
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When Liberty Mutual Workers Comp said I needed an Independant Medical Exam, they gave me a choice of three doctors available in my area. I quickly called all three and found out which ones were "disc friendly" and went to the one with the most experience in ADR. One doctor was totally against ADR so I stayed far away from him.

If you are asked for an IME, ask for a choice of different doctors. You can find out within minutes if they are disc friendly or not.
__________________
12/16/03 Work Accident
Herniation and DDD at L4-L5
4/1/05 Discectomy
Epidurals and facet injections
5/15/06 Discogram confirmed L4-L5 DDD also an asymptomatic L5-S1 tear
10/24/06 L4-L5 Prodisc surgery with Dr. Goldstein
CAT scans & X-Rays show ossification
Trigger Point Injections, Medial Branch Blocks, Acupuncture, Weekly Deep Tissue Massage
10/27/08 Discogram (positive L5-S1 tear)
11/25/08 L5-S1 fusion with Dr. Goldstein
FAILED BACK SYNDROME
Liberty Mutual WC
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  #20  
Old 03-25-2006, 12:00 AM
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Eddie, I think there is some confusion between what is an Independent Medical REVIEW vs and Independent Medical EXAM (IME).

Go Big Red, I have PacifiCare and was denied all appeals. I applied to the Ca Dept of Insurance for an Independent Medical Review of my case. I used to live in CA before moving out of state. I was a resident out of state when I requested my Indep Medical Review. I called first to make sure I shouldn't be filing with my own state's Independent Medical Review. Since PacifiCare is based out of CA they told me I was filing it in the right place??? Have you called both your state in addition to the state of CA to make sure you are requesting the review in the right place?

I'd love to hear why (specifically) they told you to file in CO. Is it because of the acquistion by UHC? I still haven't received any notice from PacifiCare that anything has changed for me.

The CA Dept of Ins, sent it out to a 3rd party company and they had 3 MD's review my file. I demand that orthopedic surgeons review my file. They only provided a resume of experience but no names. I was only able to get the names of the MD's PacifiCare used to deny my claim. NOne of them were orthopedic surgeons.
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