Did your insurance pay? Let's help one another - Page 4

NCFUSED · #31 04-13-2005, 01:40 PM

Juli,

I also have UHC and was denied both for a pre-certification and 2nd appeal, with UHC saying ADR surgery is an "unproven service".

My company is self funded / insured, so my final appeal has been in the hands of HR Benefits Committee since end of March.

From what I found out is that if your company is self funded insured, the appeals process is a waste with the insurance company (took 5 months to get 2 denials from them), because with a fully insured policy, only the company's HR/Benefits Dept. can dictate a change in policy allowing the surgery....

Juli · #32 04-13-2005, 02:41 PM

Curiouser and curiouser. Well, I just called my HR and they confirmed we are self-insured. She said to submit the request to UHC and if they deny it to then contact HR for the appeal. She was not familiar with this particular situation but said the only way to find out was to ask, of course. Now I just have to get a doctor to stop waiting for me to become fully disabled before they recommend it! I have an appointment on May 10th so should be armed with some good info after our NYC event. I am going to also send my diagnosis and MRIs to the Alpha Klinik and see if they will respond before my appointment so I will know if I am even a candidate, though I believe I am.

Thanks for the info, I am learning so much here. What a resource!

Juli
DDD L3-L4 on down since 1990

bmills · #33 04-13-2005, 04:14 PM

Had my second level appeal yesterday. It was a 10 minute conference call with three (doctors) on the appeals committee from the insurance company. My attorney represented me in the meeting.

Our main point is that the insurance policy states that procedures are covered if there is adequate peer review information for the specific procedure showing its efficacy. Or at least to that affect.

The appeals committee had no questions for us. They just listened. We stated how there is much peer review information supporting ADR. We followed up with questions asking them to define 'adequate' peer review data, how much data is required, what data, etc? If they will answer those questions specificially, it should be feasible to be able provide enough data to meet the definitions since there is a large amount of data out there now supporting the benefits of ADR.

One thing I've learned with my attorney is; the important thing to know is - what exactly does your policy state? With adequate peer review information and with a doctor's recommendation for a specific service, they should be covering my ADR.

I really don't think the insurance companies can go much longer denying the procedures based on the fact they are 'unproven, experimental, and investigational'. There is just too much data available that goes against that claim, in addition to the fact that is has FDA approval. Maybe I'm crazy...

They will provide their answer within 5 days.

Thoughts...?

Brady

ESL · #34 04-13-2005, 04:36 PM

I think what NC-ADR meant to say was if your company is "self-retained or self-insured" not "fully insured" only the company can dictate changes or exceptions to coverage........

My pre-auth does not have descriptions next to the numbers....sorry.

Juli · #35 04-14-2005, 09:51 AM

OK, thanks though, very good info.

Brady, who is your insurance company? I must believe you are correct with your final statement:

I really don't think the insurance companies can go much longer denying the procedures based on the fact they are 'unproven, experimental, and investigational'. There is just too much data available that goes against that claim, in addition to the fact that is has FDA approval. Maybe I'm crazy...

You may be crazy anyway

but I do believe the insurance companies must be on the verge of capitulating.

bmills · #36 04-14-2005, 10:34 AM

CIGNA HMO.

No logic with health insurance companies on this issue...

ans · #37 04-14-2005, 01:36 PM

Juli,

But there isn't good long-term data on ADR's. At least we know with fusion, that many eventually w/lead to "failed-back syndrome".

biffnoble · #38 04-14-2005, 02:56 PM

Hi Bmills:

What's the reference: [CIGNA HMO.] indicate?

Thanks.

bmills · #39 04-14-2005, 03:06 PM

Biffnoble, Juli asked for the name of my insurance company previously in the thread.

Brady

biffnoble · #40 04-14-2005, 03:22 PM

Bmills:

So your coverage is HMO. Very interesting. Are there ADR providers in your Group/State?

If you need to go out of Group/State what would you use as a basis for requesting HMO coverage?

My take on HMO's is that they'll: fight to keep subscribers in Group and in State and if your surgery is required and not elective they'll force you to accept what they deem to be an appropriate "accepted standard of care".

Do you have a report from an ADR (other expert) stating that the NECESSARY/REQUIRED (non-elective) treatment for your condition is ADR?

Maybe the concept that non-ADR could be considered sub-standard care and damaging to the patient could be considered a basis for suit against HMO's who refuse to pay for ADR.

However in the HMO situation I wonder if the subscriber is stuck with non-ADR that is considered an acceptable standard of care.

This gets really complicated for cases that require out of country care. Multi-level cervical ADR for example.

I wonder when the first law suits against insurers grounded on the argument that denial of ADR forces the insured to accept sub-standard care (trad spine surgery) with resultant long term ongoing damage to the patient, e.g. adjacent level degeneration caused by fusion, will be filed?