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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.


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  #1  
Old 05-06-2008, 05:30 PM
mmarsh mmarsh is offline
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If anyone has had success in getting a state agency to overturn their ins co, I'd surely like to see what you have. BS of CA has denied me again and so now I'm off to the Dept of Ins, state of CA. Any helpful hints would be appreciated. Having trouble finding cervical studies, especially peer to peer reviews. Anybody got anything? Thanks in advance.

Missy

mdm798@aol.com
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fusion L4-5, Dynesys rods L3-4, fusion c5-6 and C6-7, current problem C-7/T-1
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  #2  
Old 05-19-2008, 11:22 AM
FIXITRIGHT FIXITRIGHT is offline
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I just won an appeal on Oklahoma Workers Compensation, (Comp Source) on a two level cervical adr C-5,6,7. Let me start with my history. I had a car crash in 2004 which led to fusions at C-3,4,5. Another crash in 2007 which messed up C-5,6,7. Fusion approved but I didn't want my entire neck fused. My Neurosurgeon said that I needed a two level adr to return to work but he could only do one level. He referred me to Dr. Zigler at the Texas Back Institute but Worker's Comp. refused the referral to get an opinion whether adr was feasable or not and they said they would never approve adr surgery. I went on my own dime to TBI to see Dr. Zigler and he said I was a good candidate and it would offer me the best chance to return to work. I got the recommendations from the two Neurosurgeons and my attorney and went to court. The Judge agreed with the Neurosurgeons and advised that as long as they agree to comply with Oklahoma Worker's Compensation pay schedule and the Certified Workplace Medical Plan then I was approved for surgery. I went into this letting the doctor know what I was up against and what I needed to get it. He had some experience with Worker's Compensation and wrote the letter and addressed it to Dr. Hisey, (my Neurosurgeon that is Worker's Comp. approved,) in Oklahoma to get it into the system so that it would be in my medical file and recognized as part.
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Crash with drunk driver 04.
C-3,4,5 fusion. L-3,4,5 damage.
Run over again 07. Suv vs. Motorcycle. Damage to C-5,6,7. 06/26/08 2 level ADR in Neck C-5,6 and C-6,7
HELMET BELIEVER!
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  #3  
Old 05-19-2008, 06:56 PM
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Terry Terry is offline
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Congratulations. It sounds like you can get it FIXEDRIGHT and move on with your life. Had to play on your signature. Sometimes you eat the bear; sometimes the bear eats you. This time it sounds like you ate the bear. I hope everything comes out OK for you now and let's hope others have the same success. We have such an inequitable health care system in this country. Some are covered, some are not and there is no rhyme or reason.

Again, Congratulations.

Terry Newton
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1980 ruptured L4-L5
1988 ruptured SI-L5
1990 ruptured C5-C6
1994 ruptured C6-C7
1995 Hemi-Laminectomy C5-C6, C6-C7 Mayo Clinic
Bicycle Accident 2004
MRI, EMG, Facet Injections, Epidural Blocks, Lumbar Discogram.
Stenum Hospital Surgery November 4, 2006
Prestige Disc C5-C6, C6-C7
Maverick Disc S1-L5, L4-L5
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  #4  
Old 05-19-2008, 07:07 PM
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CindyLou CindyLou is offline
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Congratulations FIXITRIGHT! Good for you for fighting the good fight, and not giving up. And I tip my hat to that judge as well. Maybe you should contact your local paper, to see if they would be interested in your story, as a human interest piece. And it would be some good PR for adr as well. Good luck as you face your surgery, and all the best to you.
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CindyLou
bicycle accident 6/19/01
2 compression fractures, T12, L1;
vertibroplasty @ above levels, 9/15/01
4/06 hip labral tear repair
4/07 Lumbar ProDisc replacement by Dr. B., 3 levels; L3-6
7/2/08 ALIF of L6-S1
7/30/08 Removed bone cement.
8/7/08 Diagnosed with pulmonary embolism, double pneumonia, collapsed left lung, pleurisy, pleural effusion.
3/10/09 right SI Joint Fusion; seeing light at end of tunnel, for first time in 8 years!!
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  #5  
Old 05-19-2008, 08:04 PM
mmarsh mmarsh is offline
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Congrats to you fixitright! I hope I get someone who has the ability to think at the state agency. It seems so simple to me that a procedure that costs over $50K less and has a very positive outcome is being overlooked because the ins co policy says to deny ADR! Is there anyone working for the ins co that is paid to think? I'm not sure because every person I asked to please explain this to me said that it's not their job! Is it anyone's job? Holy smokes! If it's cheaper and better what are they waiting for?

Missy
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fusion L4-5, Dynesys rods L3-4, fusion c5-6 and C6-7, current problem C-7/T-1
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  #6  
Old 05-20-2008, 04:31 AM
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Terry Terry is offline
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They don't care about your health as their real mission is to save money and report to shareholders. That is the true essence of our health care system and why it leads to discrimination and inequity in payment and reasoning. If health care became mandated to some level with a degree of accountability on people for taking care of their own health (A reward system if you will for people making healthy lifestyle choices based on good, sound, educational, and prevention focused health care) we would have a system that would work for the people instead of for the profit mongers. Now wouldn't that be lovely.

Terry Newton
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1980 ruptured L4-L5
1988 ruptured SI-L5
1990 ruptured C5-C6
1994 ruptured C6-C7
1995 Hemi-Laminectomy C5-C6, C6-C7 Mayo Clinic
Bicycle Accident 2004
MRI, EMG, Facet Injections, Epidural Blocks, Lumbar Discogram.
Stenum Hospital Surgery November 4, 2006
Prestige Disc C5-C6, C6-C7
Maverick Disc S1-L5, L4-L5
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  #7  
Old 05-20-2008, 06:13 AM
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CindyLou CindyLou is offline
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Amen to that Terry. Our healthcare system is a complete embarrassment, being the wealthiest country in the world.
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CindyLou
bicycle accident 6/19/01
2 compression fractures, T12, L1;
vertibroplasty @ above levels, 9/15/01
4/06 hip labral tear repair
4/07 Lumbar ProDisc replacement by Dr. B., 3 levels; L3-6
7/2/08 ALIF of L6-S1
7/30/08 Removed bone cement.
8/7/08 Diagnosed with pulmonary embolism, double pneumonia, collapsed left lung, pleurisy, pleural effusion.
3/10/09 right SI Joint Fusion; seeing light at end of tunnel, for first time in 8 years!!
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  #8  
Old 05-20-2008, 08:18 AM
FIXITRIGHT FIXITRIGHT is offline
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I don't want to get too optomistic because they could appeal the decision but, I don't think they will. I also said it wrong. They said no and I took it to court so, it actually was not on an appeal however; that makes it a better win by not having to appeal a court decision. I merely challenged their no. Still working on getting surgery scheduled. I hope that this will help all of those that come after me.
__________________
Crash with drunk driver 04.
C-3,4,5 fusion. L-3,4,5 damage.
Run over again 07. Suv vs. Motorcycle. Damage to C-5,6,7. 06/26/08 2 level ADR in Neck C-5,6 and C-6,7
HELMET BELIEVER!
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  #9  
Old 05-20-2008, 12:06 PM
LBP LBP is offline
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Posts: 446
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Missy,

Sorry to put a damper on things but Ca Dept of Ins upheld Pacificare's denial of my 2 level Charite ADR surgery request. Then I requested another review for a hybrid (charite/fusion) and when Pacificare/UHC denied that too, the CA Dept of Ins wouldn't even look at the appeal because they said it was the same as my initial request. That was a few years ago, maybe it's better now.
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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
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  #10  
Old 05-20-2008, 12:47 PM
mmarsh mmarsh is offline
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Other than my spine, I'm the healthiest 51 year old I know! I walk at least 2 miles every day, work out for 1 1/2 hours 3 days a week, play golf 1-2 a week (All of this when healthy, now I'm only walking), so Terry's idea of a payoff for good behavior is okay by me! I don't have high blood pressure, high cholesterol or any other health issues, just an old spine! Wish they would look at the big picture for a change and reward those of us who are not bleeding them dry! LBP- I hope the state agency has changed as well. Since they don't have to put their results online like the Dept of Managed Health, I don't know if anyone has been successful at appealing the decision of the ins co for ADR. I'm hoping that the dissertation I wrote to them sways them with the logic and information that I included. I wish you all the best of luck with your issues.

Missy
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fusion L4-5, Dynesys rods L3-4, fusion c5-6 and C6-7, current problem C-7/T-1
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