ADR Paid For? Email Me

[Researcher]

I will be submitting an appeal for denial of coverage of ADR in the near future. In the precedence section of the appeal, I need to refer to as many specific individuals whose insurance company approved payment for their ADR procedure. It does not matter whether it was cervical or lumbar, single-level, multi-level or hybrid. If this is you, I will be FOREVER grateful if you could send me;

First Name, Last Name
City, State
Insurance Company
Procedure Approved
Date Approved

Many ADR patients desperately need this information to support their appeals. If you do not mind me sharing this information with other patients making appeals, please state this in your email. If you would prefer not, I will honor your request and keep the information private. You can forward the information to the following email address.

adrpaidfor@comcast.net

If you would like to communicate with me first to develop a comfort level that I am just a regular guy trying to get what I should from the insurance company and help other patients at the same time, please send a note to the same email address.

Thanks,

Phil

[Cindylou]

Good luck Phil. CL

[Justin]

Good luck, Phil. To those providing information to Phil: I've had Spine Patients send me approval letters, etc. in the past and the best way to keep your information private is to remove all identifiers (your name, medical record number, social security, date of birth, etc. etc.). The easiest way is to make a copy of the original document and then take a big, black marker to "de-identify" it.

Many Spine Patients were extremely helpful with my appeal in 2003 (sending approval letters, supporting documentation, etc.).

It's great to see Spine Patient Society Members reaching out to one another.

[mmarsh]

Phil

Best of luck to you! The more of us that can get insurance approval the weaker the insurance companies stance becomes. I hope you get loads of approval letters from people and are able to share them with us all. I know I'll be needing some of them myself in the near future. You go buddy!

M-

[Jack-of-all-trades]

It might help to get a copy of last month's Consumer Reports. They had a good write-up about health insurance companies by state. One point of interest was that not all insurance offered by a particular company is the same. For instance, BCBS of say California might deny coverage where BCBS of Virginia would cover it. It might help to support your case.

I found out that my insurance company, depending on if my surgeon and the insurance companies review thought it would work, would pay for one level but not multiple levels.

[Researcher]

I saw the CR report, but did not read it in detail. Yes, not all BCBS's are the same. There is even variation within a given BCBS, where they have unique plans for large corporations, etc. Precedence (where you prove that the insurer has paid for the surgery before) is important in appealing denial of coverage. If you can show that they paid for it for someone under the exact same group as you, you are instantly a winner. The next best thing is to show a trend of coverage by other groups under the same parent organization. Then lastly, you show a trend of coverage by a variety of insurers. I doubt I will be successful locating someone with my exact insurer that got ADR paid for, but it's possible. I plan to put together a list of the last two categories.

The number of levels is not really that important in the insurance coverage argument. You can have surgery done anywhere on the planet, so, in general, you are not bound by the FDA.

Phil

[trkdoc714]

Just because you get a pre-approval doesn't mean you'll get re-inbursed by an insurance company. My insurance company told me I didn't need pre-approval, just submit the claim after I got the billing. Simple, right?

To date, I've been only partially reinbursed by Aetna. I'm still trying to convince them that I wasn't able to walk out of the hospital and go home the day after surgery.

The main point they focused on at the beginning was exhausting all conservative treatment options. Even though they paid for all of the procedures, I still had to get the records from the surgeons, hospitals, pain management doctor and radiologist reports from the first visit forward.

Next was proving medical necessity. The 11 ESIs, 2 discectomy/ hemi-laminectomies and five offers of surgery (mostly fusion at 2 to 4 levels with full laminectomies thrown in be 2 surgeons) were enought to satisfy the investigator(s).

I also made the comparison of costs between two to four level ALIF fusion and the two level ADR ($110,000 avg v.s. $37,000) and the various studies outlining the quicker recovery differences in multi level ADR v.s. fusion.

I actually got to speak with an investigator in the midst of all of this. The lead investigator had no background in orthopaedic or neurological medicine. I overloaded her with information on fusion and ADR. She approved the procedure soon afterward.

When I got the check I was disappointed to see the amount was only for the procedure and not the aftercare. I'm in the middle of appealing that as we speak. Fortunately the final appeal is with my HR department. They seem to be a little more reasonable than Aetna. The fact I've returned to work full time and not missed any work due to my back problems since the surgery has gravity with them.

Good luck with your insurance company. I'll be happy to help if needed.

Bob

[KanRunMo]

To Trkdoc714
I am very impressed by your persistance. The fact that you got your ADR procedure paid for is so great. I am at the very beginning of my journey to solve problems for my back. You give hope to us all on getting insurance payment for ADR surgery.

[Metalneck07]

Bob- I was suprised to hear that Aetna did not cover all of your surgery. I have Aetna PPO of Georgia (private insurance).
They paid for all of the surgery including 3 days at the hospital. If I can provide information to you to help be completely
reinbursed from Aetna please let me know. With all that we pay in premiums,copays,co-insurance,etc. we deserve every penny that is their responsibilty paid. Good luck.
Caitlin aka Metalneck07

[trkdoc714]

KanRun,

The best ammo I had was the education I got from this site regarding the different types of procedures, outcomes and costs. The investigator wasn't as well schooled as I was. I think she just threw in the towel when she couldn't find a way to dispute the fact I was 100% fixed.

Good luck with your journey. We'll help all we can!

Bob

Caitlin,

My company is self insured. Aetna just administered the plan, so I got typical insurance company treatment. They've paid for everything except for the 6 days aftercare in the hospital. It's in appeal with my Benefits department. I've been waiting on a slow moving system without making too much noise. If the last appeal fails, I intend on contacting someone in upper management to help.

In hindsight, I should have sent copies of the entire preceding appeal at each appeal level. I wasted an appeal by having to backtrack with information already submitted in the prior appeal. I sent only the letter of medical necessity outlining why I needed hospital care for 6 days after surgery. The responded by rejecting the second appeal for not having any background information (previous conservative treatments, surgeries, etc.) accompanying the letter.

I'll let you know how it turns out. You'll probably hear me all the way in Dahloniga when the check hits!

Thanks for your offer though.

Bob