Need evidence that Medicare Advantage plan has paid for 2 level Lumbar ADR surgery

[Juli Ann]

Hi everyone,

I have Social Security disability and Medicare ins with Cigna as the Medicare advantage plan. I am appealing a denial for a 2 level surgery with Medicare. I have been working on this all year. I am up to the Medicare Appeals Council level. The next level is the highest, Federal Court, won't that be fun!

Anyway, both Medicare and Cigna are only approving me for a single level. If anyone has had a 2 level surgery paid for by a Medicare advantage plan, I would like to get a copy of maybe an approval letter for surgery or a "Medical claim detail" for surgery services already paid. I think this would really help my case. I only have until Jan 15 2010 to send it to the Medicare Appeals council. If anyone can help me, please let me know ASAP.

Thanks, Juli

[Harrison]

Juli,

By now, you've probably done some deep digging through the Medicare regs, so you may already know about these:

However, replacement of purchased equipment can be made for:

Certain prosthetic devices (which replace all or part of an internal body organ, or replace all or part of the function of a permanently inoperative or malfunctioning internal body organ. Some examples include Parenteral and Enteral Nutrition (PEN), insertion trays, catheters, drainage bags, skin barriers, lumbar-sacral orthosis (LSO), prostheses (leg, foot, breast, knee, ankle), cardiac pacemakers, prosthetic lenses, maxillofacial devices, and devices which replace all or part of the ear or nose.)
Limited orthotic devices (items used for the correction or prevention of skeletal deformities. Some examples include a shoe that is an integral part of a leg brace or special shoe and inserts used for the prevention or management of foot ulcers in diabetics.)

http://www.medicareadvocacy.org/FAQ_PartB.htm

Also, see attached...and also the fine print.