Exciting News is HERE!!! ---> "Alpha ADR Appeal" -- Laurie Todd

**Justin** · 07-04-2009, 03:57 PM

"Alpha ADR Appeal"

Spine Patient Society™ Members please read the following disclaimer before reading the post and the attachments below:

"I am sharing this appeal with you because it was successful. A winning appeal is a good appeal. However, this is not an example of how I write an appeal. If you want to see how the Insurance Warrior does it, you will find a complete sample appeal plus commentary in my new CD: The Sample Appeal: More Insurance Warrior Wisdom."

This appeal was written two years ago. I challenge you to find more up-to-date peer-reviewed medical journal articles. The patient who wrote it was a doctor. She had lost an appeal or two before she got to me. She won this one with the help of my first book, Fight Your Health Insurer and Win, and a little coaching from me.

I have updated this appeal in two ways. First, I changed the carbon copy list to include the correct decision-makers. Second, I eliminated all of the attachments. I do not attach anything to appeals -- except referral letters from in-network doctors. No studies, no articles, no nothing. Insurers don't read them, they do not help your case. What you need to do -- as the author has done here -- is to read the scientific articles yourself, and QUOTE them in the body of your appeal.

There is too much medical detail in this appeal. The purpose of an appeal is to INTIMIDATE, and tiresome ongoing medical detail does not intimidate insurers. Just tell about the mistakes they made, the bad advice they gave, and the things that they did wrong.

Further, you will each need to build your Precedent List. This is a case-by-case list of all of the times that insurers have paid for this before. It is a very powerful part of any winning appeal.

I have also included my nutshell advice -- "Ten Steps to a Winning Appeal" -- to help to use this example, and to get you on the right path.

My two books are available exclusively from my website: http://www.theinsurancewarrior.com/

Happy and peaceful Insurance Warrior-ing,

Laurie Todd

**treefrog** · 07-05-2009, 12:11 PM

That is a very helpful document, in that it gives me something to build on.

That Precedent list is really a sticking point isn't it? In most every thread I have seen asking for instances of insurance paying for ADR, the list is very short, and consists of mostly cervical ADR.

I think my first step is to submit a claim for reimbursement. But I want to have the appeal document started before I send it, in case there is a time limit.

I wonder if positive outcome after the fact should be brought up in an appeal? I mean I am now convinced that my surgery is a complete success, I am ready to go back to work, and my pain is nearly non-existent. And I am just coming up on 6 weeks post-op.

As far as pointing out mistakes or bad advice I was given by insurance-related doctors, I guess just that one doctor recommended fusion and another hybrid surgery, and I don't have spinal instability would be bad advice. That ADR is the better treatment for degenerative disc disease/discogenic pain.

Then I think I need to make the case that the surgeon's experience is of utmost importance in outcome, and therefore Dr. Bertagnoli was my choice. The surgeon recommending hybrid surgery, does not have the experience, having only done a dozen or so hybrid surgeries. And regardless, hybrid is not the correct treatment for me.

This entire process, just thinking about it, is so frustrating and depressing.

I really wish I had felt up to going through this process before I had surgery, though I don't know if it would have been any easier. But with the pain I was in, I couldn't fathom taking on the hassle.

**Katie** · 07-05-2009, 11:36 PM

Cathy, I have been battling it (pre-approval) for over a year and a half with nothing in sight yet, insurance wise. I wish there were more positive outcomes, but haven't seen any so far. So don't beat yourself up about doing things differently.

Justin, I appreciate all you can give on this, as I am facing a formal appeal against the Insurance with an informal board, and need all I can to help win this. (As you already know ;-) )

I have to admit that I am getting very, very tired of the whole effort, and even going through this information is almost more than I can bear. One day at a time....

But edited to add that this is very good material, and I'm going to be ordering the newest book right away. It looks like it will help me polish things off nicely. Thank you.

**Justin** · 07-06-2009, 12:19 AM

Originally Posted by Katie

Cathy, I have been battling it (pre-approval) for over a year and a half with nothing in sight yet, insurance wise. I wish there were more positive outcomes, but haven't seen any so far. So don't beat yourself up about doing things differently.

Justin, I appreciate all you can give on this, as I am facing a formal appeal against the Insurance with an informal board, and need all I can to help win this. (As you already know ;-) )

I have to admit that I am getting very, very tired of the whole effort, and even going through this information is almost more than I can bear. One day at a time....

But edited to add that this is very good material, and I'm going to be ordering the newest book right away. It looks like it will help me polish things off nicely. Thank you.

I completely understand how you feel--I've been there too before. It helped when I took a day to step aside and not think about everything. It gets overwhelming...it's exhausting, and it's completely ridiculous that Spine Patients have to do so much of the leg work.

Like you said, just take it one day at a time. The good news is that you all have the Insurance Warrior and her materials to help you--those that came before you weren't so lucky.

Her materials help people get 10 steps ahead...most people submitting a claim or an appeal do it incorrectly and focus on things that ultimately don't matter to insurance companies. Take her words of wisdom and use them to win your case.

I know it stinks, but keep your head up and fight, fight, fight!!!

**Katie** · 07-06-2009, 03:38 AM

Thanks so much for the encouragement. It helps immensely. I wish there was something I could do to pay back all the support I've gotten here. It is truly priceless, especially when the days have black clouds.

**Justin** · 07-06-2009, 11:08 AM

Originally Posted by Katie

Thanks so much for the encouragement. It helps immensely. I wish there was something I could do to pay back all the support I've gotten here. It is truly priceless, especially when the days have black clouds.

No problem Katie! That's why the Spine Patient Society exists: to unconditionally support Spine Patients. While supporting Spine Patients, we also want them to become well informed about their spinal disorders so that they may ultimately be completely confident in making the "hard decisions" about their own health and well-being.