ADRSupport Community  

Go Back   ADRSupport Community > General Discussion > The Big File

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.


Reply
 
Thread Tools
  #1  
Old 06-20-2006, 12:48 PM
go*big*red go*big*red is offline
Senior Member
 
Join Date: Jun 2005
Posts: 123
Default

Hello, again.

I feel like I'm very needy, always needing questions answered and opinions from everyone, and yet cannot add or answer anything for anyone. I'm an ADR recipient wannabe and therefore, do not have the expertise of everyone else here. Nuff of that!

This is the progression of things that have happened in a nut shell with the insurance company after final denial leading up to and including independent medical review.

<LI>Received a letter offering either a second level internal review or independent external review which they send a form for. The internal review request would be done by letter, the external review request done by filling out a form per their final denial letter to me explaining their appeals process.

<LI>With the help of my surgeon's office, we filled out and sent in the request for the external review. They disregarded that request and set up an internal review by use of a panel review over the phone. Stating that that's the way they usually do it.

<LI>Under the stipulations of the "Second Level Internal Review" which I DID NOT REQUEST, they said that I could "be assisted by counsel, advocates and health care professionals". When I requested that my surgeon be present, they denied that request. When I requested that the Charite' representative be present, they denied that as well.

<LI>I had the link posted here showing that UHC had, at the time I printed the chart, approved 3 ADRs. The doctor on the panel review denied that. When, in fact, had I printed a current chart, it would have shown that in fact 6 had been approved and one was in Colorado.

So, that's the sorted chain of pertinent events. Do I have a case? Do you think I've been lied to and hoodwinked and maybe could use this information to get the disc approved? Or is this just the way it goes?

The Charite rep says that because the FDA has approved the disc for only a single level procedure and that the remaining levels need to be intact, that an external review at this point would be hard at best. Probably wouldn't do any good.

The reason why I'm bringing this back up now, even though my surgeon has now suggested the Dynesys system is that the Colorado Division of Insurance faxed me the copy of the denial letter and the letter mentioned above with the form for the external review along with this comment.

"I wanted to make sure you had a copy of the co's 4/25/06 letter to Dr. Pettine w/the forms you may sign (yourself) to bypass other reviews & go directly - "external review"

This was sent to me on the 18th of June. So, I'm not sure if they have a copy of my denial letter yet from the panel review.

OMG - What a friggin mess! So, what do you all think?

Sorry I'm not adding alot to this forum, just alot of stinking questions.
__________________
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.
Reply With Quote
  #2  
Old 06-20-2006, 02:40 PM
Harrison's Avatar
Harrison Harrison is offline
Administrator
 
Join Date: Oct 2004
Posts: 6,917
Default

Please don't feel like you're not adding anything to the forum -- on the contrary. Questions often help other people too!

I think your situation is complicated, and you would benefit by having a good lawyer. I am happy to try to help you find one that is Colorado based.

There are many folks on the board from Colorado, so hopefully they will respond here or privately to your plea.

Email me or PM when you can!
__________________
"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
Reply With Quote
  #3  
Old 06-20-2006, 03:33 PM
go*big*red go*big*red is offline
Senior Member
 
Join Date: Jun 2005
Posts: 123
Default

Thank you, Harrison and . . . . done.
__________________
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.
Reply With Quote
  #4  
Old 06-20-2006, 08:24 PM
sahuaro sahuaro is offline
Senior Member
 
Join Date: May 2005
Posts: 455
Default

Wish I had some words of wisdom to add but I think the idea of consulting a lawyer is the way to go. You need to know that you are forging a road for all of us who are or may be fighting for insurance coverage--so I appreciate your posts and support and thank you for fighting the good fight.
__________________
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
Reply With Quote
  #5  
Old 06-20-2006, 09:03 PM
letteski letteski is offline
Senior Member
 
Join Date: Mar 2005
Posts: 814
Default

sahuaro makes a good point if you sat back and just took the crap that the insurance companies are dishing out to you, you would be a spineless human. Don’t give up and don’t stop asking questions you help more then yourself.

I am not up on you case and with out a signature do you need a 1 or 2 level? Sorry for asking as we both of us have been around for a while but I can’t remember the specifics. Have you thought of clinical trials or getting out of CO for surgery other Doctors may have better luck. I have seen it happen here lately.
__________________
Paulette
ProDisc L5-S1 W/Dr Delamarter Aug 23, 2005
L5-S1 DDD Diagnosis 12/04
T-12 Compression Fracture 10/04
C-7 Spines Process Fracture 5/99
http://prodisc2.blogspot.com/
You are my Rock God in you I can do anything
Reply With Quote
  #6  
Old 06-20-2006, 11:22 PM
Texas-T Texas-T is offline
Member
 
Join Date: Apr 2006
Posts: 72
Default

I really feel for you and your fight to get treatment. I agree with everyone else, it may be time to at least consult with an attorney. You're workers comp, right? What about the state insurance commissioner?
__________________
Tear L5/S1 (Pain generator)
IDET 2003 L5/S1 Failed
Shots, MRI's, PT, Drugs & All that Jazz
ADR L5/S1 May 17th 2006 w/Dr. Bitan
http://adrrecovery.blogspot.com/
Doing GREAT and feeling very lucky!
Reply With Quote
  #7  
Old 06-21-2006, 06:35 AM
go*big*red go*big*red is offline
Senior Member
 
Join Date: Jun 2005
Posts: 123
Default

Well, thank you all for your kind words and encouragement. Paulette, you will see that I updated my signature line. I had my signature line on the old forum, but had a heck of a time logging in on this new one and was just glad to finally get logged in that I just didn't care to go into it all.

The insurance commissioner's office did call yesterday afternoon. Her take is to go ahead and request the external review anyway as all the problems I had during my panel review is common. That's why the commissioner's office ALWAYS suggests to do the external and forego the internal when offered the choice.

She is giving Pacificare the benefit of the doubt in thinking that her letter to them and their letter to me crossed in the mail or something wacked like that. ANYWAY, doesn't make sense to me, but she said to go ahead and it couldn't hurt, right?

All I do is fill insurance form out again (5 minutes) and submit with it any new information which she suggested that I print and submit the most current chart from the link I got here. I'm going to cut and paste it in this post when I'm done for anyone who needs it.

So, I think that's all for now, and again - thanks for making me feel like not such a slug!

Here's the link - VERY VALUABLE!!!
http://www.charitedisc.com/charitedev/domestic/patients...r2/docs/coverage.pdf
__________________
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.
Reply With Quote
  #8  
Old 06-21-2006, 09:17 AM
LBP LBP is offline
Senior Member
 
Join Date: Aug 2005
Posts: 446
Default

Hey Big Red,

Last year I went through an external review with the CA Dept of Insurance for a 2 level Charite. They upheld PacifiCare's denial as "investigational and experimental."

More recently I've tried to get approved a hybrid (fusion at L5/S1 and Charite at L4/5) . When I called Pacificare to follow up...they said the surgery was denied. When I got the copy of the denial letter it only referred to the Charite and said nothing about the fusion. I made them clarify what their position was on the fusion part of the surgery. It only took the assistant an hour or two to review my file with the medical director and get back to me with an approval of the fusion half of the surgery...but they continued to deny the Charite part. I am appealing with CA Dept of Ins on this now.
__________________
Injured 9/01
Annular tears L4/5 & L5/S1
denied adr by insurance for 2 level charite as well as hybrid fusion at L5/S1 with Charite at L4/5.

New ins paid for 2 level lumbar prodisc surgery on 4/7/08 (at age 39) with Dr. Westerlund, at Core Orthop
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
Going for a Second Opinion Nairek The Big File 4 02-16-2006 01:00 AM
Bertagnoli 2nd opinion???? Alastair The Big File 4 02-16-2005 08:59 AM


All times are GMT -4. The time now is 11:27 AM.


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