BCBS-TX - Final update !*@&#^$%!

[jss]

I had a two level ADR in Barcelona in Nov 2009 and have pursued BCBS-TX for reimbursement from that time until January 2011. Here is what will be the final update on my unsuccessful crusade for reimbursement.

Denial 1: BCBS-TX denied the initial request claiming that my surgery was not "medically necessary".
Appeal 1: I responded with a 68 page appeal chronicling my decade long struggle with cervical problems and citing the written testimony of five doctors that I'd seen in the prior year that all prescribed ADR.

Denial 2: BCBS-TX's reply to that appeal took three months and denied my request again, this time stating that multilevel ADR was "investigational".
Appeal 2: I reciprocated with a 100 page appeal in which I showed that multilevel ADR has a 19 year history which includes thousands of successful outcomes, and has been studied and discussed from multitudinous angles in dozens of clinical studies involving hundreds of patients and resulting in dozens of peer reviewed articles; all of which converge on the safety and effectiveness of multilevel ADR.

Denial 3: BCBS-TX's reply to that appeal took only two weeks and denied my request yet again, this time stating that it was company policy to deny multilevel ADR. Read it yourself; "The medical review unit has reviewed the claim and has determined that the procedure does not meet our medical policy criteria."
Appeal 3: I went to my CEO, who referred me to the HR director. She was happy to send an email to some executives within BCBS-TX on my behalf.

Denial 4: BCBS-TX's reply to her took 15 weeks, and cited the following reasons for denial:

• The initial claim was submitted directly to BCBS-TX instead of BlueCard World Wide
• BCBS-TX has a policy that deems multilevel ADR to be experimental
• "The member" traveled to Spain for the purpose of receiving medical treatment

Appeal 4: There won't be one. This fourth denial cited three reasons; the first of which whose patent falseness is exceeded only by its manifest absurdity. If anyone wants to conclude that BCBS-TX sits in its Dallas offices looking for reasons to deny claims, that they would deny any claim on the grounds that the initial forms were filed to the wrong address, can be used to support that conclusion. Since I had irrefutably repudiated BCBS-TX's claim that multilevel ADR was experimental in my second appeal, they reiterated here what they used in their third denial; that covering multilevel ADR is against company policy. With the third reason, BCBS-TX finally had found an ace-in-the-hole that there is no argument against; that reimbursing treatment in another country when the member travels there explicitly for treatment is against company policy. Combining this third reason with the fact that when my HR director told me of the reply from BCBS-TX, that she looked me straight in the eye, cocked her head and eyebrow and firmly stated that this was the "final final reply"; she is done and will not assist me in pursing this.

Details of my condition that I've not discussed here could have resulted in paralysis or death had I not undergone spinal cord decompression ASAP; and as such it was impossible for me to postpone treatment. Had I had the months that it would have taken to present all of my information to BCBS-TX before treatment, I am much more confident that they would have covered the multilevel ADR, for the sole reason that it cost half of what they'd already agreed to cover in the US. But their position appears to have been, "Hey look guys, we can pay 50% of what we already told him we'd cover, or because circumstances have forced this poor fool's hand, we have the contractual opportunity to deny coverage and save 100% !!!"

All things considered, the double M6 ADR surgery in Spain was an easy decision to make. Given the same circumstances and knowing what I know now, I'd absolutely do it again. Sixteen months later, I am still free of pain, can still work, run, jump, dance and do almost everything that is natural for a 48 year old man. I'm still out $28k, but all things considered; that makes me the winner!

[Cindylou]

Yes, you are the winner Jeff!! And good that you can ultimately see it that way. Otherwise, it would eat you alive. You in your heart of hearts know you did everything possible to get your surgery covered, and they still denied it. (Reading your story really brought back the memories of my own thesis writing of all my appeals and denials.) At the end of the day, you indeed ARE the winner, and you got your life back. Pardon me, but screw them. CL

[JPJH]

Jeff,

You gave it a good go!! Tried harder than I did that is for sure. I stopped after my second appeal. Not easy to swollow, but time to get on with life. It will come back and bite all those people in the butt who worked against you and the rest of us. Carma can be a....well you know. I remember when I was doing my appeals against Anthem / BC I actually got one of their people to tell me if I was The CEO or the family member of the CEO or on the Board of Directors of A/BC I would have got my suregery in the U.S. or overseas, but since I am not one of "those people" it was not going to happen. That was off the record of course. I don't think he like doing what he had to do there at A/BC, but hey it's a job I guess. Not sure how folks live with themselves? I guess they get sucked into the culture and really believe what they are doing is really best for us. Silly people......

JPJH

[jss]

Thanks for the encouragement guys.

There are a few things that make it easier to accept the situation... First, I went into this fully expecting that I'd not be reimbursed. Second, the surgery has so far been a resounding success.

It still aggravates me that the sole reason that BCBS-TX didn't reimburse me is that through bad faith that they were able to find a reason not to.

[Justin]

Thanks for the encouragement guys.

There are a few things that make it easier to accept the situation... First, I went into this fully expecting that I'd not be reimbursed. Second, the surgery has so far been a resounding success.

Jeff, thanks for sharing your experience () with BCBS. Even though you weren't successful with your insurance appeals, your surgery was a complete success!

You fought the good fight!

[lunaazul21]

Sorry u r out of 28k, but you have a new lease on life. Congratulations on your decision to have surgery. Can you please tell me who your surgeon was?
Thank you and congratulations again!!!!

[jss]

Blue Moon,

My surgeon was Dr Pablo Clavel of the Barcelona Spine Center in Barcelona, Spain. Surgery was at Quiron Hospital in Barcelona. I was 100% ambulatory a few hours after surgery and the second day after surgery (and the five after that) I walked many miles per day around Barcelona touring the city. Since surgery I've been SCUBA diving in the Caribbean, run three half-marathons, two full marathons and been in a 100 mile bicycle race. (results not typical) Not bad for someone that couldn't open a door without assistance the two months before surgery.

Good luck on selecting an implant and a surgeon. Both are daunting tasks that require hundreds of hours of research. So far I'm convinced that I made the right decisons for me. I hope that your outcome is similar.

BTW: I sincerely hope that "21" in your name doesn't mean that you are experiencing such problems at 21 years of age.

Good luck, Jeff

[rhatzy]

I had a 2 level Maverick Lumbar a little over 3 years ago and it was the best $39,000 I have ever spent. Compare that to the hundreds of thousands of dollars I could have lost due to being disabled is a mere pittance not to mention the lifetime of pain and drugs and depression. I doubt that I would have lasted very long any way. Pain and drugs is an evil thing and makes life hollow.

Thank God for Stenum and Ritter-Lang and all the excellent surgeons around the world, except the USA, who give people hope.

Mark

[lunaazul21]

Thank you for your response. And congratulations on the success of your surgery!

When you had your surgery in Germany how long did you stay in germany for your recovery? And how long did it take for you to fly back home? How did you manage the long flight? What did you do if you had follow up visits with the surgeon?

claudia

[lunaazul21]

The previous post was meat for both rhatzy and jss : P

Jss, your surgery was in Spain, the previous post questions are directed to you as well. How long did you stay for recovery in spain, ect

Thanks!