How dare they do that????

[Greg]

Back in november 2009 i tried to get BCBS of VA to approve a 2 level ADR.....didnt expect them to approve but had to try anyway. Of course, they denied. At this point I have well passed my out of pocket cap for the year so minus co-pays for Dr visits, the surgery would have been 100% paid for. Since we only had a few months left I pushed to have a fusion done instead figuring that wouldnt be an issue to get approved. I have 2 herniated discs, one pressing on my bilateral proximal S1 nerve roots. All the MRI's, CT's, Discograms, XRAY's, and a gigantic binder full of every possible treatment option other than surgery.

We submitted the pre-auth for 2 level fusion and they DENIED IT! I couldnt believe it. They claimed my file didnt show any signs of "Instability" thus denying me because the "services are not medically necessary." I couldnt believe it. We went through several levels of appeals and still no luck. At this point I had screwed up my pain mgmt by taking a few extra on some bad days, getting a pill count, being short and dismissed from the office. This was a lot of bad news at once. No surgery, no meds, NO END IN SIGHT.

I'll try to sum this up quit. I tried some other things to fix my back...no luck. I finally found a Dr 3 hours away in Durham, NC doing a clinical trial for fusions using stem cells to aide the fusion. Yeah! An option for poor ole me to get a surgery when the insurance company denied a perfectly legitimate claim. I went to see the dr, discussed everything (which he couldnt believe they denied me) and decided we would try to get the ins to approve but if not go through the clinical trial.

My theory as to why they denied the fusion is I had met my out of pocket cap and if they could hold me off for 2 months then I would have to fork out $2,500 for the surgery. I just got a call today that after 20 minutes on the phone trying to get the approval from the insurance, THEY APPROVED IT. No issues, no questions, i dont even think she sent my images and records. That just proves to me there that they denied me because they wanted me to pay some. Why else would they deny one, then approve another instantly when the surgeries requested where THE EXACT SAME SURGERY!

I justt cant believe them. At least on the bright side I have a date (MAY 14th!!!!) and can see the light at the end of the tunnel starting to turn on. Has anyone else had an experience like this with the insurance companies? Could they have done something illegal given my circumstances?

[WPKat]

Greg,

It certainly might seem like someone rubber stamped it with the hope you'd give up and they'd save a boat load of money (maybe they are paid commission based on how much money they save the insurance company).

But to be fair, there could be other explanations: The first claims representative might not have been paying attention to your claim (a human error); he/she was so tired that they decided to stamp all the remaining claims with the DENIED stamp they happened to have in their hand so they could go home (overworked and underpaid) ... or they did hope you'd give up on the first round and save the insurance company some money (pure unethical behavior).

You'll never know why the first claim was denied, but good for you for staying in the fight after you got shot down and for not taking their denial lying down!



K

[jss]

Greg,

Sigh.... I have an experience that is kind of opposite of yours. BCBS approved ADR for me in 2008 (twice). Because I was improving with non-surgical treatment, I canceled the surgery. Then in 2009 (after I'd met my deductible) things flared up again so I decided to have the surgery. Then they denied.

Jeff

[Cindylou]

Unbelieveable, isn't it? No rhymn or reason. Accept twice, then deny later. And Greg, altho the Nazi pill count makes my blood boil, on the good side, at least you got your surgery scheduled AND approved. Things are looking up for you buddy. It's all good now.

[scduggan]

Dear Greg,
Congratulations on getting a surgery date. My guess is that you will have better sleep now and have a lot more peace knowing you have a plan. I don't sugar coat things....the surgery will probably rock your world. But, you will be headed in the right direction for getting out of pain. This will carry you through. WooHoo!
CD

[runagain]

Greg,

I cannot get started on ins. issues as my blood might just boil.
There is evil that walks our earth and they work for blue cross.
Hee. hee. Actually, that is a joke.
But I wonder how they sleep at night, especially the CEO of Well Point, who makes around 11 K a year.
The people that work for BC have ruined several lives, including mine.
And I believe it is all for profit.
Document everything, even with the approval.
If they can, they will try to stick u with the bill.

[Greg]

Greg,

Sigh.... I have an experience that is kind of opposite of yours. BCBS approved ADR for me in 2008 (twice). Because I was improving with non-surgical treatment, I canceled the surgery. Then in 2009 (after I'd met my deductible) things flared up again so I decided to have the surgery. Then they denied.

Jeff

Which BCBS do you have Jeff? Is it a regular BCBS or an employer funded one that it administered by BCBS? BECAUSE I STILL WANT ADR...well actually a hybrid is what I really wanted; L5/S1 can be fused and ADR L4/L5. I guess when it comes to insurance companies beggers (or should I say "paying customers") cant be choosers....oh wait, we should be

Unbelieveable, isn't it? No rhymn or reason. Accept twice, then deny later. And Greg, altho the Nazi pill count makes my blood boil, on the good side, at least you got your surgery scheduled AND approved. Things are looking up for you buddy. It's all good now.

YES I DID!!!! Although they just pushed the surgery date back several weeks from May 28th to June 18th....doctor hasnt recovered as quickly as planned from his emergency spine surgery

Greg,

I cannot get started on ins. issues as my blood might just boil....AGREED!
There is evil that walks our earth and they work for blue cross.....AGREED!
Hee. hee. Actually, that is a joke.
But I wonder how they sleep at night, especially the CEO of Well Point, who makes around 11 K a year.
The people that work for BC have ruined several lives, including mine.....AGREED!
And I believe it is all for profit.....COULDN'T AGREE MORE
Document everything, even with the approval.
If they can, they will try to stick u with the bill.

Now the only thing I have for approval-wise to document is when I go to the "authorization" section of my BCBS website I can see what all has been approved. I have it printed out so hopefully if they get money hungry again it will be good enough back up. I'm just worried now that since they pushed my surgery back from 5-28 to 6-18 that my good ole luck is gonna kick in and there gonna screw me over and decide there back to denying me again....HOPEFULLY NOT THOUGH!

[jss]

Greg, I have BCBS of Texas. One of my doctors told me that BCBS-TX not only routinely pays for ADR, but for "off label" implantation of ADR devices. That's not been what I've been seeing.

[Greg]

Greg, I have BCBS of Texas. One of my doctors told me that BCBS-TX not only routinely pays for ADR, but for "off label" implantation of ADR devices. That's not been what I've been seeing.

So are you saying that the doctor said they are paying but in reality (from what you see) their not paying?

[jss]

What I'm seeing is people complaining on these sites that BCBS-TX will not pay for their ADR. BCBS-TX approved my ADR in 2008; I had the surgery in 2009, and then they declined the claim after the surgery. So from what I'm seeing is that they are not paying. However, someone for whom BCBS-TX refuses to pay is more likely to be on these forums.

IF BCBS-TX really does tend to pay, I can't tell it by reading these forums.