insurance appeal help needed?

**Lance** · 02-11-2011, 07:19 PM

Hello and thanks for being here. I am a new member and I'm struggling to come to grips with the insurance appeal process. Is there anyone out these that can help me with my appeal? So far I've had no luck. Look forward to hearing from you soon
Thank you Lance

**KBear** · 02-11-2011, 07:20 PM

Welcome to the forum! I'm no help on the appeal though, lost all of mine and never got them to agree to pay.

**bigdogchief76** · 02-12-2011, 12:06 AM

A little bit more info would be useful...

What's the appeal for? What level are you at? Have you read your SPD? Insurance plan?

**Justin** · 02-12-2011, 07:49 AM

Hi Lance,

Welcome to the Spine Patient Society.

As Matt stated above, a little more information regarding your situation would definitely help us help you.

Also, when you get a chance, please create a signature: New Members, Read First: How to Create a Signature (Your Spine History).

**Cindylou** · 02-12-2011, 10:20 AM

Welcome Lance,

Glad you found us. I hope you can shake your appeal up and gain approval. It is an uphill battle so put on your boxing gloves, that's for sure. As the others already stated, if you can provide us with a few more details, we can probably help you a bit better. Good luck! Cindylou

**Lance** · 02-12-2011, 03:45 PM

Thanks for the welcome and the words of encouragement everyone. My doc and I agree I really need disc replacements between L3 L4 and L4 L5 so he submitted the pre authorization to my insurance company BlueCross/Blue Shield of Illinois and they shot down the request. I have never done anything like this before and was wondering first if anyone has had success with this insurance company recently??? Secondly I was looking to see if anyone has a proven appear letter template I could start with?
Thanks again everyone.

All the best
Lance.

**bigdogchief76** · 02-19-2011, 02:33 AM

From my understanding most US health insurance company's are not authorizing benefits for multiple level ADRs. 2 or 3 of them have just begun authorizing benefits for single level ADR for cervical and lumbar regions.

So I am not a bit surprised by BC/BS of Illinois denying benefits to you.

First and most important is to find out what your summary plan dictates for your appeal process.

From there its about taking your time and doing research. The terms "experimental" and "medically not necessary" are code words for "we don't want to pay"

I highly recommend spending the 32 dollars and buying the book and appeal process written by Laurie Todd (Insurance Warrior). While her book is somewhat centrally focused on a cancer treatment, there are some VERY valuable tools and tips in how to deal with an appeal process.

There is no way to sugar coat this so I won't: You face a very large battle in front of you with this. Add the fact that you are suffering with back pain and it becomes an even more difficult chapter in your life. Take each step one by one. Start with reading the info from Ms Todd. From there its about you fighting for your rights as a paying insurance member and your rights as a patient. The final outcome may not be everything you hoped for (insurance company might still deny) but the experience gained and knowledge acquired will be beneficial as a spine patient and as a paying insurance member.

I would also look at the cost of potentially getting overseas treatment. Sometimes insurance will cover for this since as it costs much less for these procedures overseas.

Lastly, I encourage you to write to your congress person and demand that one of the first steps in healthcare reform starts by making it illegal for insurance companies to dictate what is and what is not medically necessary. Put the power back into the doctors hands.

Don't be afraid to ask questions on here: a bounty of knowledge and life experience is at your fingertips

**Cindylou** · 02-19-2011, 10:50 AM

Originally Posted by bigdogchief76

From my understanding most US health insurance company's are not authorizing benefits for multiple level ADRs. 2 or 3 of them have just begun authorizing benefits for single level ADR for cervical and lumbar regions.

So I am not a bit surprised by BC/BS of Illinois denying benefits to you.

First and most important is to find out what your summary plan dictates for your appeal process.

From there its about taking your time and doing research. The terms "experimental" and "medically not necessary" are code words for "we don't want to pay"

I highly recommend spending the 32 dollars and buying the book and appeal process written by Laurie Todd (Insurance Warrior). While her book is somewhat centrally focused on a cancer treatment, there are some VERY valuable tools and tips in how to deal with an appeal process.

There is no way to sugar coat this so I won't: You face a very large battle in front of you with this. Add the fact that you are suffering with back pain and it becomes an even more difficult chapter in your life. Take each step one by one. Start with reading the info from Ms Todd. From there its about you fighting for your rights as a paying insurance member and your rights as a patient. The final outcome may not be everything you hoped for (insurance company might still deny) but the experience gained and knowledge acquired will be beneficial as a spine patient and as a paying insurance member.

I would also look at the cost of potentially getting overseas treatment. Sometimes insurance will cover for this since as it costs much less for these procedures overseas.

Lastly, I encourage you to write to your congress person and demand that one of the first steps in healthcare reform starts by making it illegal for insurance companies to dictate what is and what is not medically necessary. Put the power back into the doctors hands.

Don't be afraid to ask questions on here: a bounty of knowledge and life experience is at your fingertips

Great thread and advice. I agree 100% with it.

CL

**Lance** · 03-08-2011, 10:59 PM

Thanks to everyone for the info. I just finished Laurie Todd’s book and she suggest composing an appeal document not a letter. Does anyone have a template I can start with. Secondly the insurance letter states "we have determined that the following procedure is to medically necessary 22857". Tomorrow I'm off for a second opinion. Question is how many additional opinions do I need??? Next question does anyone have a suggested check list of the required documents for a successful appeal? I really don’t have much spare time being a single parent, working full time and attempting to research all the necessary info? Thanks again Lance

**Cindylou** · 03-08-2011, 11:20 PM

Originally Posted by Lance

Thanks to everyone for the info. I just finished Laurie Todd’s book and she suggest composing an appeal document not a letter. Does anyone have a template I can start with. Secondly the insurance letter states "we have determined that the following procedure is to medically necessary 22857". Tomorrow I'm off for a second opinion. Question is how many additional opinions do I need??? Next question does anyone have a suggested check list of the required documents for a successful appeal? I really don’t have much spare time being a single parent, working full time and attempting to research all the necessary info? Thanks again Lance

I wondered where you went and what happened to you Lance. Great that you read Laurie Todd's book. That's an excellent start. You ask how many additional opinions you need. I would personally recommend a minimum of 3. 4 would not hurt your case at all. Plus, it is so beneficial to see how they line up in terms of their final recommendations. Do they all agree? Do 3 out of the 4 agree? That sort of thing. I'm not much help for the template or the check list as I did not end up having a successful appeal, unfortunately. But others will chime in soon. I wish you the best of luck securing a successful appeal for your surgery! Cindylou