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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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Insurance reimbursement
After almost a year and half of researching to figure out what was wrong with me and finding the best way to fix it, I am 99% sure I will be seeing Dr. Clavel very soon for a 3 level Cervical ADR.
I have researched this forum deeply trying to get the best answer just to remain confused as to the correct procedure and order of achieving a Reimbusement from my Insurance Company. I have Blue Cross Here is the question: 1. I have read people just going ahead and having the surgery, then sending the surgery info in to Blue Cross for reimbursement. 2. I have read also that people have gone the old preapproval route, sending their information in before. I have already been through the appeals process for a one level all the way to the external review level, where I backed out because I have a multiple level problem. Any assistance, guidance or oppinions will be soooo appreciated. Thank you
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Body Builder/Trainer C5 Radiculopathy- with only major weakness in right bicep and deltoid, no pain. Unacceptable Insurance denial of ADR Grade 2+ spondylolesthesis at L5/S1 (I can deal with the pain as long as I am active) May 8 2015----3 Level Cervical ADR @ C4-C5-C6 With Dr. Clavel |
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Hello Iron,
I was one of the lucky ones who DID get reimbursement from BCBS. I did not get preapproval from my insurance because they don't like the idea that you will leave the states (in my case) to seek healthcare anywhere else; especially a multi-level which was not FDA approved here. I could not have ADR in 2013 due to the multi-level/adjacent to a fusion issue. My only choice was to choose a surgeon elsewhere; otherwise endure multi-level fusion and a restricted lifestyle. I did go ahead with the surgery anticipating that it would be an out of pocket expense - and yes....I went through my savings, borrowed some money, and sadly sold off some personal possessions. However, my happy thought through all of this was that I would get my life back and enjoy it (priceless!) My BCBS is through a Chicago Union. I collected all receipts which included a detailed financial statement (in euros and US $) from the surgeon, hospital, and rehab center. I also requested a statement of diagnosis from my surgeon with his surgical notes and opinions. I submitted everything to the BCBS Worldwide network (part of my plan), but they didn't know what to do with it (???) I resubmitted everything directly to our contracted carrier's office. They submitted everything and it took almost a year from the date of surgery to the date I received my check. They covered everything - 100%. How could they not? My actual surgery was a pittance charge for what would have been charged for the surgical intervention here in the states, plus I have a more positive outcome that would not require additional surgery in the future....Saving THEM money! I made sure that I included a letter outlining all of the pre surgical requirements that needed to be fulfilled (therapies, injections, and any other non invasive interventions). All non-surgical/non-insurance related expenses became a medical tax deduction. My transportation, additional hotel charges, rental car, etc. was submitted and I was able to "eek" back a healthier return too. I believe persistance is the key with dealing with insurance companies. All too many times they deny claims for absurd reasons - or they made an error. Many people don't bother to question the denial or they make a phone call, but don't get the response they want. I DO! I believe it takes at least 3 phone calls to clear up one little error. Do not give up - perseverance is the key to success. My submission to BCBS was at least 3-4" thick of paperwork - I think I may have scared them away (someone has to read it all). Good luck to you. LauraB
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2006 C 5/6 discectomy and fusion 2008 Automobile Accident C3/4 leftward bulging of intervertebral disc mild narrowing of left lateral recess C4/5 central and rightward bulging of disc and osteophyte causing mild right neural foramen stenosis narrowing and right lateral recess narrowing C6/7 Central disc bulging and osteophyte and hypertrophy of ligamentum flavum canal stenosis and narrowing of bilateral neural foramina Sept 9, 2013 Scheduled with Dr. Bierstedt C4/5 & C6/7 M6 |
#3
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File and Appeal
File for reimbursement, they will haggle and not want to pay, but APPEAL, if they do not the first time.
Make sure you give a detailed history and tell them that this was NOT elective. Did get some reimbursement. But I had to fight, call and APPEAL. This is ALL the more reason for 100% REPEAL of this Monstrosity, they call the ACA. TORT Reform and 50 state access for ALL insurance. Best of luck.
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Jerry, Somewhere Ohio L2-3 herniation, two days before Thanksgiving, 2012, Discectomy/Laminectomy, 3/13 Numbness in the right leg, lateral femoral, gone, July 10, 2014 L45 M6 ADR, July 15 PLIF L5-S1, Not able to access L51 Anterior. |
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Hi Laura, i hope u are doing well and living pain free. Im in the middle of an appeal for hybrid coverage here in the states even though i dont really want that. Im wondering how you did this. Were u in the appeals process? Did u talk to them first and try to get a reimbursement agreement before u went over there. Im thinking of trying to convince insurance to pay for me to go over there and save them money.
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36 year old male ddd s1-L5-4-3 Life long abuse and neglect, 2013 Discectomy semi-successful 2015 Steroid shots dont work anymore so i cant work |
#5
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Also, was it "blue card world wide" i have bcbs of nc with the blue card world wide coverage.
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36 year old male ddd s1-L5-4-3 Life long abuse and neglect, 2013 Discectomy semi-successful 2015 Steroid shots dont work anymore so i cant work |
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I haven't seen Laura around since she posted on my thread. Take a look at her two posts here: https://www.adrsupport.org/forums/f6...tml#post109793
If these don't answer your questions, I suggest you send her a PM. Wishing you wellness.
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2006: epidural shots did nothing; 2 surgeons recommended 2 level fusion, I declined. 2007 - 2010 4 foraminotomy and cord decompression cervical surgeries and 2 endoscopic discectomy T7-T8 surgeries; total 6 with Dr. Jho (Pittsburgh,PA) My C6/C7 autofused around 2009. 2013 - 2015: epidurals 3 times (again did nothing) and 4 Radiofrequency ablation (or RFA) procedures. 2016 more RFAs, hit the 10 year mark of this insanity and pain, 3 level M6-C ADR with Dr. Clavel May 19, 2016 |
#7
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Document EVERYTHING
...and go straight to them, BCBS will reimburse.
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Jerry, Somewhere Ohio L2-3 herniation, two days before Thanksgiving, 2012, Discectomy/Laminectomy, 3/13 Numbness in the right leg, lateral femoral, gone, July 10, 2014 L45 M6 ADR, July 15 PLIF L5-S1, Not able to access L51 Anterior. |
#8
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what she said
I agree with Laura B.
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54 yr old female 5'7" 147 lbs. non-smoker conservative treatments failed 2007 fusion @ C4-6 peek cages, failed due to long term use of cox-2 inhibitor 2008 revised C4-6 donor bone, plate & screws 2009 fusion with Roi-C @ C3-4 2015 MRI & CT mjr ddd @ C6-7, segmental kyphosis at C7-T1, 2-level M6-C prosthesis by Dr. Clavel Barcelona Spain 2019 H.O. formed behind M6-C @ C6-7 left nerve rt & in spinal canal. 2020 Revision C6-7 to a CP-ESP prosthesis by Dr. Schmitz Dusseldorf Germany |
#9
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Sorry guys. I haven't been around too much lately only due to a job change and dealing with my mom's cancer.
I went with the BCBS Worldwide and found myself moving in circles. I eventually contacted local office "Union," and explained the situation. I copied and resent my file - I think the size of it scared them into submission. They took it over and paid. From my perspective, if I was traveling and had this issue, I would be treated overseas using the "best practice" available. In Germany, they have been performing this surgery, successfully, for over 20+ years. That doesn't seem like "exploratory" or "experimental" procedures. This is what I made clear in my explanation of the diagnosis and treatment. It also was important to show that you have exhausted all forms of "non-invasive" pre-surgical protocol procedures prior to surgery; being your last resort. I included a timeline history of cervical injections, therapies, and diagnostic testing.
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2006 C 5/6 discectomy and fusion 2008 Automobile Accident C3/4 leftward bulging of intervertebral disc mild narrowing of left lateral recess C4/5 central and rightward bulging of disc and osteophyte causing mild right neural foramen stenosis narrowing and right lateral recess narrowing C6/7 Central disc bulging and osteophyte and hypertrophy of ligamentum flavum canal stenosis and narrowing of bilateral neural foramina Sept 9, 2013 Scheduled with Dr. Bierstedt C4/5 & C6/7 M6 |
#10
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Laura, I'm so sorry to hear about your Mom's cancer. I wish you both wellness and hope for her full recovery. I know it's difficult because I helped both my parents through their illnesses and end of lives. I'm so sorry you and your family are facing these challenges. Sending prayers.
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2006: epidural shots did nothing; 2 surgeons recommended 2 level fusion, I declined. 2007 - 2010 4 foraminotomy and cord decompression cervical surgeries and 2 endoscopic discectomy T7-T8 surgeries; total 6 with Dr. Jho (Pittsburgh,PA) My C6/C7 autofused around 2009. 2013 - 2015: epidurals 3 times (again did nothing) and 4 Radiofrequency ablation (or RFA) procedures. 2016 more RFAs, hit the 10 year mark of this insanity and pain, 3 level M6-C ADR with Dr. Clavel May 19, 2016 |
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blue cross, cervical, dr clavel, multilevel adr, refund |
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