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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  
Old 02-13-2017, 06:40 PM
Nestletea Nestletea is offline
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Join Date: Nov 2016
Posts: 33
Default Florida Blue - Denied ActivL Lumbar TDR

I had lumbar TDR scheduled February 15, 2017 with Dr. Rolando Garcia in Miami, Florida. Their office submitted for approval and the procedure was denied due to being "experimental/investigational." I then submitted an expedited internal review. Florida Blue had 72 hours to make a decision and I was again denied. This was after I sent in approximately 1000 pages of medical records and my surgeon completed a peer to peer review twice. The first peer to peer was done unfairly (family physician to surgeon). My surgeon then asked for a second peer to peer review with another board certified spine surgeon. Florida Blue again denied the procedure. Today I sent in an Expedited external review. This contained all of my medical records, 25 research studies that favor lumbar TDR vs fusion and all of the insurance companies that offer positive coverage (this includes some BCBS plans). There is another 72 hours to make a decision. If anyone has any other suggestions, it would be greatly appreciated!

Thanks
__________________
1/8/2016 - Microdiscectomy L5/S1
3/17/2016 - Cervical Disc Replacement C5/C6 (Mobi-C)
10/19/2016 - DeKompressor Wand L5/S1
1/16/2017 - Cervical Radiofrequency Lesioning
3/15/2017 - Dr. Pablo Clavel: Cervical Disc Revision C5/C6 (M6-C) and Lumbar Disc Replacement (M6-L)
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  #2  
Old 02-15-2017, 11:00 PM
WakesurfMike WakesurfMike is offline
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Join Date: Nov 2016
Posts: 37
Default you can file a complaint with your States insurance consumer affairs

http://www.myfloridacfo.com/Division...eedourhelp.htm

you can file a complaint with your States insurance consumer affairs
__________________
WakesurfMike
2007 Herniated L5/S1 Lifting changing X-ray tube at work. MRI PT/ Steroid shots/med
2009 switched to Remote/phone support
2010 workman’s comp lawsuit
2011 Microdiscectomy approved 80% pain relief
2011-2016 few flare ups but would always get beter after a few days.
6/2016 Pain is not going way
07/2016 MRI, tramodol, Nucynta, Celebrex
08/2016 Regenerxx PL-Disc shot- didn’t work at all
10/2016 can't even stand or sit for work for 30 minutes before pain gets worse
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  #3  
Old 02-15-2017, 11:17 PM
WakesurfMike WakesurfMike is offline
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Join Date: Nov 2016
Posts: 37
Default maybe a lawer or activL® Artificial Disc Patient Assistance Line (PAL):

I found this recommendation for a lawyer that will help with getting insurance to pay from Dr Bertangnoli web site. I am sure it won't be free.

http://www.dr-bertagnoli.com/patient-information.html

David Suddendorf, Attorney-at-Law
415.806.6599
dave@davidsuddendorf.com
http://davidsuddendorf.com/adr-insurance-reimbursement/

Have you tried the Active L Patient Assistance line? They have staff available to help free of charge. You would have to get your surgeons office to call the them.

https://www.soactivesofast.com/low-b...nt-information

Resources include:

A reimbursement support line for pre-authorization, appeals and external review
Template letters, coding guide and supporting literature
Ongoing reimbursement landscape monitoring and analysis

activL® Artificial Disc Patient Assistance Line (PAL):
Monday through Friday, 9:00 am - 6:00 pm ET
Tel: 844-245-1140
Fax: 844-285-1330
Email: cynthia@patientassistanceline.com
__________________
WakesurfMike
2007 Herniated L5/S1 Lifting changing X-ray tube at work. MRI PT/ Steroid shots/med
2009 switched to Remote/phone support
2010 workman’s comp lawsuit
2011 Microdiscectomy approved 80% pain relief
2011-2016 few flare ups but would always get beter after a few days.
6/2016 Pain is not going way
07/2016 MRI, tramodol, Nucynta, Celebrex
08/2016 Regenerxx PL-Disc shot- didn’t work at all
10/2016 can't even stand or sit for work for 30 minutes before pain gets worse
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  #4  
Old 02-22-2017, 06:28 PM
Nestletea Nestletea is offline
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Join Date: Nov 2016
Posts: 33
Smile Expedited External Appeal Denied

My frustration has continued, as the expedited external appeal that was filed through Florida Blue was denied. This has exhausted all of my insurance options in the United States. Therefore, I will be headed to Barcelona on March 13th to have a lumbar ADR with Dr. Clavel. I have thoroughly researched the neurosurgeons in Germany and Spain and based on patient outcome and insurance provided by Dr. Clavel's office for the surgery, the decision was easy. Also, I have researched the activL and M6L and discussed both discs with several US and European surgeons. In the end, I will go with the M6L. This disc has an 80 year lifespan vs. the activL that has a 30 year lifespan. I feel at peace with the decision and look forward to feeling better in the near future!
__________________
1/8/2016 - Microdiscectomy L5/S1
3/17/2016 - Cervical Disc Replacement C5/C6 (Mobi-C)
10/19/2016 - DeKompressor Wand L5/S1
1/16/2017 - Cervical Radiofrequency Lesioning
3/15/2017 - Dr. Pablo Clavel: Cervical Disc Revision C5/C6 (M6-C) and Lumbar Disc Replacement (M6-L)

Last edited by Nestletea; 02-25-2017 at 06:39 PM.
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