ADRSupport Community  

Go Back   ADRSupport Community > General Discussion > Insurance Hell

Insurance Hell All insurance-related matters are here: Medicare, worker's compensation, appeals, denials, insights, wins, losses. PRICING is here too. Note: This forum has posts from 2006 forward. Older ones are in the Big File.


Reply
 
Thread Tools
  #1  
Old 05-30-2007, 06:29 AM
stuschulz stuschulz is offline
Junior Member
 
Join Date: Mar 2007
Posts: 12
Default

Has anyone with Blue Cross Blue Shield of Illinois, Texas, New Mexico or Oklahoma had their lumbar ADR covered?

Thanks,

Stuart
__________________
DDD
L5/S1
Reply With Quote
  #2  
Old 06-19-2007, 01:01 AM
epiphaknee epiphaknee is offline
Junior Member
 
Join Date: Dec 2005
Posts: 21
Default

See Blue Cross Blue Shield Policy 127:

http://www.regence.com/trgmedpol/surgery/sur127.html

But also see: http://www.globalpatientnetwork.com/...news-wsj.shtml

Insurers have taken a mixed view of the device. Kaiser Permanente, the California-based health maintenance organization, endorsed the Charité last November after requests by its doctors but the Blue Cross and Blue Shield Association concluded there isn't enough evidence that the device works. Most of the nation's 40 independently owned Blue Cross and Blue Shield plans are following that advice.

One exception is Horizon Blue Cross Blue Shield of New Jersey. It decided the Charité is right for some patients and doesn't cost much more than spinal fusion, says senior medical director Stanley Harris. He puts the cost of the procedure, including doctor and hospital fees, at $67,000 per patient. J&J says a more typical figure is $35,000 to $45,000.
Reply With Quote
  #3  
Old 06-21-2007, 01:45 PM
djscal djscal is offline
Senior Member
 
Join Date: Apr 2005
Posts: 232
Default

I got Regence Blue Shield to pay for my ADR surgery after a pretty viscous fight which involved 3 appeals, hiring an attorney for thousands of dollars and hundreds of hours of my time. Even after they reversed their decision and paid, they clearly stated in their letter to me that my case was a one off special circumstances case and their policy was clearly not to pay for ADR.

My case is strange because they initially did pay and then attempted to rescind payment about 9 months after paying for the surgery. Insurance companies by law have one year to rescind payment for any reason of their choosing. An overzealous blue shield bean counter looking for career advancement must have thought that I would roll over and accept defeat and be intimidated by their b.s.; not so.

I wish you luck in your fight.

It is absolutely sickening what is going on in this country with respect to health insurance.
__________________
Age 34
DDD L5-S1, bulge and Grade V annular tear.
SED 2/15/05 - no luck
Charite @ L5-S1 8/2/05 with Dr. Regan
Struggling with facet joint pain.
Reply With Quote
  #4  
Old 06-21-2007, 01:55 PM
robby robby is offline
Junior Member
 
Join Date: Jun 2007
Posts: 15
Default

djscal,

How many levels did you have done? I have been denied for 2 level and in the middle of the appeals process now.

Robby
__________________
39 years old, Female. Loved to run and workout.
August, 2004 Micro surgery for L4-L5
August, 2006 Second Micro surgery for L4-L5
May, 2007 Discogram revealing DDD at L3-L4 and L4-L5.
Dr. Recommended 2 level ADR. Denied three times.
Reply With Quote
  #5  
Old 06-21-2007, 01:59 PM
djscal djscal is offline
Senior Member
 
Join Date: Apr 2005
Posts: 232
Default

One level, it's in my signature.

I hired the lawyer between my 2nd and 3rd level appeal (independent medical review) with the insurance company. Having him on the phone was priceless. The intimation was that we will sue the living hell out of you for punitive damages and intentional infliction of emotional distress if you don't get with the program. It worked.
__________________
Age 34
DDD L5-S1, bulge and Grade V annular tear.
SED 2/15/05 - no luck
Charite @ L5-S1 8/2/05 with Dr. Regan
Struggling with facet joint pain.
Reply With Quote
  #6  
Old 06-21-2007, 02:12 PM
robby robby is offline
Junior Member
 
Join Date: Jun 2007
Posts: 15
Default

Sorry....didn't read the signature....I have already spoken with my lawyer about this and he is ready to get involved when the time comes. Anthem Blue Cross Blue Sheild is my provider. Thanks for the giving me hope!
__________________
39 years old, Female. Loved to run and workout.
August, 2004 Micro surgery for L4-L5
August, 2006 Second Micro surgery for L4-L5
May, 2007 Discogram revealing DDD at L3-L4 and L4-L5.
Dr. Recommended 2 level ADR. Denied three times.
Reply With Quote
  #7  
Old 06-22-2007, 01:34 PM
djscal djscal is offline
Senior Member
 
Join Date: Apr 2005
Posts: 232
Default

There is definately hope. To minimize cost with the attorney I recommend that you do as much work for him as possible. That includes printing out articles for him including your benefits manual and all of your correspondence with the insurance company including letters from doctors stating that this is the best course of treatment for you. Basically you do all of the leg work and he brings the firepower to the showdown. This is how I got away with only paying for 6 hrs of his time. I probably spent 100 hours to his 6.

Remember, they don't want to go to court as it is bad PR for them and very expensive so if you make them believe that you will sue they are more likely to back down. Everything is a negotiation - even with the insurance company.

It's a sickening thing to do, but try to think like them. What would you do in their situation? Answer: the most inexpensive possible solution. If that means paying to avoid a major lawsuit, they will probably do it. You could also team up with other ADRSupport members and file a class action suit. That will make them wake and pay attention.

I can't believe we are still talking about this issue in 2007 3 years after the Charite was FDA approved. (sic)
__________________
Age 34
DDD L5-S1, bulge and Grade V annular tear.
SED 2/15/05 - no luck
Charite @ L5-S1 8/2/05 with Dr. Regan
Struggling with facet joint pain.
Reply With Quote
  #8  
Old 06-22-2007, 11:56 PM
D. Coley D. Coley is offline
Junior Member
 
Join Date: Jan 2007
Posts: 12
Default

Please read my post about insurance approval recended a new way in the Big File forum!!!!

I thought I had won the fight and Blue Cross OKlahoma won!!

I have also talked to lots of other people that actually made the surgery date and then got stuck with ALL the bills afterward and have the insurance APPROVAL letter too.

The loop hole according to BC/BS is that the corporate offices send out the approval letters but ultimately the STATE offices (in-network ppo office) determine whether or not to pay....that's where the billing after the surgery goes to.

I'm angry but thanking the man above that my surgery was post poned several times and then cancelled by the surgeon because they (BC/BS) don't pay the bills and glad I didn't get stuck with them.

I would have become known as the BC/BS BOMBER if I would have got stuck with all the bills after the surgery AND having an approval letter AND paying $600. a month in premiums.

I now DONT TRUST ANYTHING THEY TELL ME!!!!!!!!!
Reply With Quote
  #9  
Old 09-21-2007, 12:18 PM
Don Don is offline
Senior Member
 
Join Date: Jul 2006
Posts: 173
Default

I have UHC and they do not cover ADR. But, I can switch to BCBS. I assumed it was BCBS of Michigan, but I checked and I would be covered by Horizen, BCBS of NJ. Any idea if that is really the case? They say that, but I have a feeling I would fall under the rules for BCBS of Michigan, becasue I live in Michigan. I'm going to make a few more calls to them, but wonder if anyone has any experience with them?
__________________
Don G.

3 level DDD L5-S1 through L3-L4.
"Compressed" L5-S1 in ~1992.
Herniation at L3-L4 and L4-L5
Fusion or ADR in near future
Reply With Quote
  #10  
Old 09-21-2007, 02:21 PM
Guest
 
Posts: n/a
Default

[QUOTE]Originally posted by Don:
I have UHC and they do not cover ADR. But, I can switch to BCBS. I assumed QUOTE]
Hi Don,

Do not waste your time with UHC if it is a PPO. I have spent 8 months battling insurance for nothing. In the end the HR director decided my health care! Also, if you switch to BCBS will they consider it pre-existing? Do not assume anything with insurance. They pull any shenanigans they can to NOT of pay.
Reply With Quote
Reply

Bookmarks

Thread Tools

Posting Rules
You may not post new threads
You may not post replies
You may not post attachments
You may not edit your posts

BB code is On
Smilies are On
[IMG] code is On
HTML code is Off


Similar Threads
Thread Thread Starter Forum Replies Last Post
Blue Cross Blue Shield ADR Denial finally reversed ZorroSF Insurance Hell 17 01-30-2014 07:46 PM
Blue Cross Blue Shield {aka Blue Crap} chasswen Insurance Hell 16 06-06-2012 06:03 PM
Technology Evaluation Center Blue Cross Blue Shield Abbe Insurance Hell 2 07-03-2007 08:30 PM
Federal Blue Cross Blue Shield misty The Big File 6 04-05-2005 12:34 AM
3rd Appeal with Blue Cross Blue Shield cavalier The Big File 10 03-25-2005 11:24 AM


All times are GMT -4. The time now is 05:55 PM.


© Copyright 2006-2017 ADRSupport.org All rights reserved.