Seeking ADR...my story

[jessmith07]

Originally Posted by treefrog

Yes, I have written off my insurance company. I don't feel like trying to fight them, with a very low likelihood of success. I have BC/BS of NC.

I also have to have 2-levels done (L4/5 and L5/6), and just got my surgery date with Dr. Bertagnoli, for May 26. My boyfriend and I are taking out a loan, to pay for the surgery. I know in this economy, it isn't the best time to try and get a loan. But if there is any way possible for you to financially swing it, it sounds like you should try.

I know I haven't really been living life, only existing. The pain has made it impossible for me to do much, that isn't absolutely necessary.

I hope that you are able to find a way to have surgery, and get rid of the pain, so you can start living again.

Originally Posted by treefrog

When you say that your husband knows of someone for whom BC/BS covered ADR surgery, was it cervical or lumbar? It seems to me that cervical surgeries are covered more easily than lumbar. What I mean is that insurance is unlikely to pay for multi-level lumbar ADR, let alone single level, but may be more inclined to cover multi-level cervical ADR. All in all though, it's very difficult to get them to pay for surgery done in the US, let alone pay for out of country surgery.

Hers was lumbar, at L5/S1. I am going to try to upload all of the pdf files that I sent that helped me successfully appeal an insurance denial for an ADR procedure. I supposed I should put it under the insurance section...perhaps someone can direct me, since I'm new at this?

[treefrog]

What great news Jess. I am so glad that it is working out for you. Hopefully, one day, it won't be so difficult for all US citizens to have ADR surgeries covered by insurance.

[jessmith07]

Originally Posted by treefrog

What great news Jess. I am so glad that it is working out for you. Hopefully, one day, it won't be so difficult for all US citizens to have ADR surgeries covered by insurance.

Keep fighting, Kathy...you might be surprised...I sure was...I really expected them to say NO a third time.

[runner]

Jess,

When your husband comes home from work, give him a big hug because he is the reason you got approved.
For myself and others who don't have federal insurance, we cannot get approved (by several insurance companies). I spent months fighting Blue Cross (still fighting them for my surgery and their mistakes on my insurance that come up regularly) to no avail. I sent them a 200 page appeal. I sent them all the foreign studies i could dig up, so they turn around send me a letter saying they will only accept US studies. ProDisc approved in August 2006 (I was scheduled for surgery in 2007, then 2008). BC wanted five year US studies past approval before they said they would approve ADR.
The same with United Health Care and some other insurance companies. The insurance companies have a double-standard when it comes to federal employees.

I am glad you got it approved so you can do the important things before surgery and not worry about where you are going to get the money for the surgery.

The reason federal employees get ADR approved is that the federal insurance companies have to accept FDA (federal agency) approved treatments. Regular BC/BS, United, etc.. don't. Aetna, Cigna, and Kaiser are among the insurance companies that approve ADR.

Sorry, if I come on strong but I consider BC/anthem/wellpoint evil. You wouldn't believe what they have done to me and I will never forget it. I pray every single night that they are brought down like the big mortgage companies and banks, but that they don't get a bailout.

Now, Jess, you don't know me from anything, but I was personally speaking to corporate BC people in my appeal. I continue to fight the insurance companies. So realize I am not upset or mad at you, I am just upset at the money-grubbing insurance companies and the state of health care in the United States.

That's the end of the soapbox speech because I don't want my back hurting more than it already is or my blood pressure up.

Runner

[jessmith07]

Runner,

I'm so sorry to hear of your ordeal, yet it makes me feel even more blessed to have fought and won. I know that I'm among the fortunate few to get the insurance company to approve this. I just hope that the more people that fight and win and share their stories of how they did it, that hopefully, eventually, the industry will turn. I was fully prepared to go to the Office of Personnel Management in Washington, as well as the Department of Insurance in SC, whose job it is to help protect consumers against insurance companies. One thing I learned in my research is that HIPAA doesn't just protect your privacy...it's more than that form you sign at the doctor's office. HIPAA is a federal law protecting consumers from the corrupt insurance companies, and while it doesn't mandate that they MUST cover certain things, what it DOES mandate is that they can't discriminate treatment within a group. In other words, if you are in a group plan with 1,000 other people, and they cover ADR for someone else, but deny it for you, then they are in violation of federal law.

In Summary, HIPAA, Title IV looks something like this:

Group health plans may exclude coverage for a specific disease, limit or exclude benefits for certain types of treatments or drugs, or limit or exclude benefits based on a determination that the benefits are experimental or medically unnecessary - but only if the benefit restriction applies uniformly to all similarly situated individuals and is not directed at individual participants or beneficiaries based on a health factor they may have. (Plan amendments that apply to all individuals in a group of similarly situated individuals and that are effective no earlier than the first day of the next plan year after the amendment is adopted are not considered to be directed at individual participants and beneficiaries.)