Got my answer to my insurance appeal...

[steve55]

Unicare will be tough. They are not one of the insurance co's who I h ave seen approve ADR based on my 7 months of browsing back pain boards. BUT, then again, doesnt mean they cant.

I noticed they mentioned your age requiring future revisions, but fusion is even much more likely to require further future surgeries as the adjacent discs wear out. It will be easy to counter that arguement since the theory behined ADR is to preserve motion so that further surgeries wont be necessary. Getting proof of this should be easy to find. Just google it. And the disc manufacturer should have the most accredited studies that will work in your favor. And lastly, you might show how ADR is cheaper than fusion. The initial response they are giving you is probably canned. By appealing with heavier duty stuff as I suggested , and combining that with Laurie todd's procedures (see below about her book), you should be able to force them to have to REALLY work to counter you.

Also, you might try compiling copies of peoples approvals with other carriers. Overwhelm them with it!! So much so, that they look stupid and negligent in not approving it. You can post on the various back boards for people to email you copies of their approvals for such proof. And most importantly, get a copy of Laurie Todd's book, the insurance warrior. Its only about $10 online. Google it, she supposedly tells you what it takes to make them jump. She knows how to scare them into doing it too. This book just might get you approved if you follow her advice. There are people on the boards who have gotten 2 level ADR's approved by insurance co's who typically dont approve ADR , such as United healthcare for example. Below are some posts I have copied and pasted as I was saving them for my own battle plan.

The freedom disc may not be so bad, it seems to me that people are doing well with all the various types of discs except for the early charite discs which would fall apart over some time. And being that its newer, it has a higher chance at being better than its predecessors. Just my 2 cents worth : )

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1. I'm sorry I have not been on the forum lately, but I'd be happy to share a general story on how I was able to secure approval from United Healthcare:

I initially saw a brilliant surgeon who is world renowned that did not advocate the ADR. My thoughts on why he didn't push for the surgery are simple: he's older and about to retire and he doesn't want to learn a new technique or risk tarnishing a wonderful career. There was a mix b/w doctors here in Oklahoma regarding the surgery itself. Yes, it's new, but the results have been fantastic so far. It's the nature of science and medicine to move forward while others remain skeptical. There's rarely a consensus among doctors, so don't be too worried about that. I listened to all opinions and did my own research and determined that the cervical ADR was right for me. I found a doctor who pushed me to get more conservative treatment before we considered the ADR surgery, but once that failed he said that he strongly believes in the surgery and that I was a perfect candidate (I'm 24 and otherwise very healthy). He said that if he had to have surgery, he would only have ADR surgery.


2.My approval took nearly a month and a half, so keep that in mind. In order to get approval for the surgery you must prove that its necessary and that its as good or better than the alternative (fusion). You do this with a "predetermination" (aka precertification) request to UHC. You will likely get denied at this point like most people. They only approve on a case by case basis at the highest level as far as i know. So this requires you to appeal the initial decision (it took two appeals for me). The denials will be based on the fact that they claim the ADR surgery with the Prestige Cervical Disc is "Unproven or Experimental". These terms are defined in your "Certificate of Coverage" under UHC. When you read the definitions (read everything related to them) you will see that the ADR surgery should be covered based on the language. The reason being is b/c its "proven" due to the FDA study that was completed for the Prestige Cervical Disc. This was the largest FDA study of its kind and received unanimous approval. This type of study suffices under UHC's definition of proven technology. So in your appeal letters you should submit the actual FDA study and highlight this issue. Your doctor should have the FDA study, or you can contact Medtronic for it (they make the Prestige).

3. I was mistreated, hung up on, and continually transferred during my many phone calls. I eventually filed a complaint with the OK Insurance Commission. Telling UHC I did this seemed to light a fire under their tails! My approval came within days. I attribute it to all of the factors I've listed though.



4.I am with you there!! I fought United for 6 monthes (2 disc replacement here) and finally took me taking the case to the VP of our company to get them to pay. We are a self funded group, but United LACKS much in the ways of their claim processes and denials.

I explain how to hack through the bureaucracy of customer service. People waste a lot of time on the phone when they should be putting things in writing. Insurance companies count on people making frenzied phone calls and giving up. Get every denial in writing, never accept the denial by phone. Appeal letters should be 20 + pages long with case studies supporting your claim, its intimidating and time consuming for them to have to wade through it. Make sure you send copies of each appeal to all the right people mainly the insurance co's chief medical director and title envelope and 1st page of document "urgent expedited appeal".Best weapon of all is to show how it will cost your insurance company less.

5.Insurance companies are really backasswards (yeah that's a word) in their approach to "helping" patients. I worked for a very large Health Insurance company for a couple of years. I can only tell you that those squeaky wheels seem to get taken care of... to the point where you may benefit from picking up the phone and calling the claims manager/VP every single day. jAnd yes I do mean every single day. Twice a day if necessary. I've seen this work over and over. They get so sick of dealing with you that take some kind of action. It it's an action you don't like you just keep moving up the chain - which is tough because the higher you go the more isolated they are from the General Public. Sounds like a crazy approach... but it can work.

[Kathy]

Thanks everyone,
When I posted, I was bummed and felt defeated. After reading all your replies, I feel ready to fight the fight and WIN! I know I have it in me, I'm a pretty sore loser and can definitely be the squeaky wheel (just ask my husband )
Can anyone share some clinical trials with me, that I can print? Any approval letters that I can print? Anything that would help me prove my case?

Thanks
kathy

[Kathy]

Glad to see all the familiar names and people here from the other site.

[Justin]

Hey Kathy,

I've been pretty busy lately. Just so you know...if you need any articles/publications to present for your appeal, I can get you them. I have access to almost every journal imaginable through school.

I have some pubs that I used during my appeal, which are somewhat dated now but they might help.

Let me know how I can help... we'll kick 'em where it hurts!

[mmglobal]

It's so frustrating to watch this happen over and over. It's not about fair, right and wrong, appropriateness of medical care, etc.... this is all about money.

They referred to an article that is more than 3 years old. We'll see newer data... much has been presented at the more recent conferences.

If you want to borrow the Laurie Todd's book, I'll send it to you. It's cheap enought that you might want to order it instead of having to ship it back to me. I have links on the GPN website.

All the best,

Mark

[Kathy]

Thank you Mark, I will look up the articles I have and let you know, so I can get the newer ones. I thought that it was odd that they used only one article and an old one at that. I think I will just order Laurie Todd's book, so I can get to reading and preparing to fight. Thanks again and thanks for this great site.
Kathy

[steve55]

Kathy, the Spinehealth mesage board was where I got the most replies when I asked for people to message me who have approval letters for ADR. Post the question on every board you know. But title it someting that has a call to action like" Need help-Lumbar ADR approvals, pls respond" . I would also post it in the "Insurance" sections of these back boards. And, to be sure your post doesnt sink to low on some of the boards due to last reply date sending it to the back of the line, you might reply to your own post every once in a while with a "thanks everyone" ,to bring it back to the top. Many people dont click back to far in date. In a matter of days I had 3 or 4 people who not only had their approval to send to me, but said they could share other approvals they collected for their own cases. Imagine showing them 20-30 approvals by various insurance carriers, and if you are lucky enough, maybe you will find a Unicare one that slipped thorugh their cracks. But follow Laurie todd's advice, she knows their weak spots and thats what will matter most in the end. Hey, if you got time on your hands, or dont have much else to do (due to not going out as much due to pain) this battle may give you some sense of purpose or something to work towards for the time being. You may as well give them hell since they are more than willing to give the same to you by their unwillingness to approve your ADR.

[ans]

I'm sorry to hear this. Maybe if you email Laurie she might have some inside information; she's a great person.

health insurance help

My best - ans

[treefrog]

Sorry to hear about the denial Kathy.

After reading all the advice here, I am encouraged. I had not even thought about applying to have my insurance company pay (BCBS of NC). I had just accepted that I would have to pay the $8000 (for the disc and supplies needed for that part of the surgery, since I was looking at hybrid surgery), if I chose to go that route. It would be great if I could get them to pay.

[Roblin]

Kathy,
I'm so very sorry to hear of your denial. Stay strong and fight this thing. You are a winner! I'm sure you will get all of the ammunition you need to fight and win.
Sincerely,
Roblin

[Maria]

In terms of adjacent level syndrome if it were fusion that were being suggested it would probably authorized and that in itself seems to have much evidence of necessity for further surgery re adjacent level problems not to mention revision surgeries.. yet because it's tried and true and been around for so long no doubt it would be authorized.

Sorry to read about the denial and hopefully it will be authorized soon. I hope you don't have to wait too long because as someone who has waited around a long time for me likey the option of ADR is out the window now because of the number of years I've waited and continued degenerative process in my spine re endplates and facets...adjacent level probs that occur anyway with no surgical intervention.

That part about being young ~ that should bode well for you in terms of recovery and that much is probably in the literature as well in terms of any surgery.