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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
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Optima - Denied
Just got the letter back from my insurance company: Denied.
Denial codes: "D84F - Not medically necessary per Medical Director - Member responsible." "The requested service is considered investigational and not medically necessary per Optima Policy Surgical 78". What a surprise...
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46yo, DDD of L4-S1. Microdiscectomy L5-L4 in 2014. L4-L5-S1 M6 ADR with Dr. Clavel - June 2015. |
#2
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Are you going to appeal?
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#3
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Romakis,
This may or may not help...see attached. Make the calls / letters anyway. It's a small effort that have a big ROI.
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"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 |
#4
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Appeal
Yes, I am going to try to appeal. Thanks Harrison.
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46yo, DDD of L4-S1. Microdiscectomy L5-L4 in 2014. L4-L5-S1 M6 ADR with Dr. Clavel - June 2015. |
#5
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Help
If anyone has any documentation to help me file an appeal, I would highly appreciate it. Please let me know and I will give you my e-mail address. Thank you all in advance!
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46yo, DDD of L4-S1. Microdiscectomy L5-L4 in 2014. L4-L5-S1 M6 ADR with Dr. Clavel - June 2015. |
#6
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Quote:
"Dr. Peggy Ebinger, MD is a psychiatrist in Virginia Beach, Virginia."
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46yo, DDD of L4-S1. Microdiscectomy L5-L4 in 2014. L4-L5-S1 M6 ADR with Dr. Clavel - June 2015. |
#7
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My appeal package
Sending the documentation today. Thank you all who helped me put it together (Jerry, Andi, thank you so much!!!).
Had a hard time finding an envelope to fit all the paperwork...
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46yo, DDD of L4-S1. Microdiscectomy L5-L4 in 2014. L4-L5-S1 M6 ADR with Dr. Clavel - June 2015. |
#8
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Wow, so the person making the decision was a freaking psychiatrist?! I'm entering into my own ADR denial hell, so this is good information to have.
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33-year-old female C3/4 Disc bulge and bone spurs C4/5 Disc protrusion C5/6 Disc extrusion with cord compression, bone spurs due to uncovertebral arthropathy, right foraminal stenosis and bilateral nerve compression. C6/7 disc protrusion Lost appeals for ADR. C5-6 ACDF on 3/10/16 ACDF never fused, and ACDF accelerated damage of the other levels. Someone please kill me. |
#9
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Appeal is also denied
As I expected, the appeal was denied as well by Optima Health. They stated that it was not "medically necessary", and that discectomy should have been used instead .
I guess I should have cut the rest of my discs out, and leave everything else as is . Man, my appeal was so thick and looked so good ...
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46yo, DDD of L4-S1. Microdiscectomy L5-L4 in 2014. L4-L5-S1 M6 ADR with Dr. Clavel - June 2015. |
#10
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That really sucks!!! Sorry to hear...
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Canadian but not into hockey (even as a woman I'm a shame to the country lol). Sporadic back problems for yrs. Severe issues 2013. degenerative disc disease 2013, disc protrusion, mild stenosis. Epidural steroid injections, chiro, massage, accupuncture, too many meds to list, Naturopath, physio, occupational therapy, kinesiologist, counselling... M6 Artificial disc replacement @l5-s1 Nov 2015, in Canada June 2016 - still struggling...Physio, accupuncture, massage, counselling... |
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