ADR Denial, BCBS Montana.

[grzz660]

I have had back problems through the years, Normal right? I was working in a highly Labor intensive Job for 15 yrs, promoted to supervisor in 2003. The back pain always went away. Used chiropractor mainly.
Thanksgiving weekend 07 I injured it again helping get boat off of an island on the yellowstone river. Two months went by then it happened. Blinding pain that would not let me go to work. Had Mri done and Doc did emergency Discectomy L5-S1, He said i fragmented the disk into 3 pieces and he had a hrd time removing them. surgery went well and had good recovery. Jan 2011 noticed some leg pain, it slowly got worse. Seen Doc in April and of corse had to try the Steroid pill and nerve blockers, Physical therapy and then a Epidural. After 5 Days Felt O.k. and went back to work. Quit chewing and working on losing 30 lbs.
June 10th the Epidural wore off and ended up in the ER on June 12th the day after my 39th birthday. They gave me 3 Morphine, 1 Flexerol, and 2 Dilloted shots to get me to walk out with my brand new walker! June 13th recieved my second Epidural and it did not work. Sat at home for a month. Lost my weight to get PRO DISC L! Went the 220 miles to the doctor and scheduled surgery! I was on my way the next week for preop and on my way the doc called and said insurance denied it they said " It was NOT medically necessary . Wow! I pay 600 a month cant walk with out a cane and it is not necessary! I kept going and got another Epidural and it it has been 5 days and i think it is working..
The doc and i are going to appeal but in the mean time I am willing to cash out retirement to get this done. I dont want to lose my Aug 12 surgery date!

[Cindylou]

I have had back problems through the years, Normal right? I was working in a highly Labor intensive Job for 15 yrs, promoted to supervisor in 2003. The back pain always went away. Used chiropractor mainly.
Thanksgiving weekend 07 I injured it again helping get boat off of an island on the yellowstone river. Two months went by then it happened. Blinding pain that would not let me go to work. Had Mri done and Doc did emergency Discectomy L5-S1, He said i fragmented the disk into 3 pieces and he had a hrd time removing them. surgery went well and had good recovery. Jan 2011 noticed some leg pain, it slowly got worse. Seen Doc in April and of corse had to try the Steroid pill and nerve blockers, Physical therapy and then a Epidural. After 5 Days Felt O.k. and went back to work. Quit chewing and working on losing 30 lbs.
June 10th the Epidural wore off and ended up in the ER on June 12th the day after my 39th birthday. They gave me 3 Morphine, 1 Flexerol, and 2 Dilloted shots to get me to walk out with my brand new walker! June 13th recieved my second Epidural and it did not work. Sat at home for a month. Lost my weight to get PRO DISC L! Went the 220 miles to the doctor and scheduled surgery! I was on my way the next week for preop and on my way the doc called and said insurance denied it they said " It was NOT medically necessary . Wow! I pay 600 a month cant walk with out a cane and it is not necessary! I kept going and got another Epidural and it it has been 5 days and i think it is working..
The doc and i are going to appeal but in the mean time I am willing to cash out retirement to get this done. I dont want to lose my Aug 12 surgery date!

grzz, your story rings all too familiar around these parts, I am afraid. That said, you have come to a fantastic community of folks who can welcome you and lend you support, while you make your appeal. There are a growing, albeit slow, group of people on here who have got their adr's covered either first time, or through an arduous appeal. So, please, don't ever give up. Keep the fight in you. Although not ideal, you could consider keeping your surgery date if you see it as critical to your wellness, and continue to fight the good fight of appeal, post-surgery. Just a thought. I wish you the best and please keep us informed how this plays out for you as we do care. Good luck and welcome too! Cindylou

[ferndog]

I have had back problems through the years, Normal right? I was working in a highly Labor intensive Job for 15 yrs, promoted to supervisor in 2003. The back pain always went away. Used chiropractor mainly.
Thanksgiving weekend 07 I injured it again helping get boat off of an island on the yellowstone river. Two months went by then it happened. Blinding pain that would not let me go to work. Had Mri done and Doc did emergency Discectomy L5-S1, He said i fragmented the disk into 3 pieces and he had a hrd time removing them. surgery went well and had good recovery. Jan 2011 noticed some leg pain, it slowly got worse. Seen Doc in April and of corse had to try the Steroid pill and nerve blockers, Physical therapy and then a Epidural. After 5 Days Felt O.k. and went back to work. Quit chewing and working on losing 30 lbs.
June 10th the Epidural wore off and ended up in the ER on June 12th the day after my 39th birthday. They gave me 3 Morphine, 1 Flexerol, and 2 Dilloted shots to get me to walk out with my brand new walker! June 13th recieved my second Epidural and it did not work. Sat at home for a month. Lost my weight to get PRO DISC L! Went the 220 miles to the doctor and scheduled surgery! I was on my way the next week for preop and on my way the doc called and said insurance denied it they said " It was NOT medically necessary . Wow! I pay 600 a month cant walk with out a cane and it is not necessary! I kept going and got another Epidural and it it has been 5 days and i think it is working..
The doc and i are going to appeal but in the mean time I am willing to cash out retirement to get this done. I dont want to lose my Aug 12 surgery date!

Hello grzzz...sorry to hear about ur denial. I too am fighting bcbs currently! Am on my external review process ( first two regular appeals got denied) Isn't it amazing how they can deem not neccesary when surgeons say you need it?:-) We just need to have Faith and try to be patient:-) Do not give up!

[sandy]

Hi im new member here, but i can tell you i had adr artificial disc cervical c4 c5, you have got to call your bcbs ask why they denied you , it may be simple as doctor did not send them all the right paper work as to why you need the adr, also do you have ppo, hmo, It took me several weeks i called them everyday , also i am in illinois but i wouldnt figure being in another state would make a denial.

[runagain]

Grzzz,

This is very surprising. Last time I looked, Blue Cross of Montana had a positive decision for lumbar ADR and did not cover cervical.
I joked about moving to Montana in order to get ADR, lumbar that is.
If they have suddenly changed their spots, that is quite weird.
I even pulled up the Montana decision when I was checking around last year.
Positive means they are supposed to cover everyone that meets their criteria. It is usually the same state to state, 6 months of treatment that does nothing, ESIs, facet joints injections, physical therapy. Get on line Grzz and look up their decision. Maybe you pulled a case worker who just denied so they didn't have to do any work.
Good luck,

R