Hello all - I just got the initial denial from Blue Cross Blue Shield for my ADR Sugery, and am looking for some advice as I begin the appeals process. My problem is a disk herniation at L4-L5. I've done everything - PT, Epidural injections, facet injections, accupuncture and most recently massage therapy and yoga, which are helping some. No one in my state has gotten the ADR approved yet and I am hoping to be the first. Any suggestions would be greatly appreciated.
All I can say is good luck. I've been going through the appeals process now for about 6 months. My dr is doing it for me with the help of J & J. My ins. co. is Pacificare who has recently merged with someone else (can't think of who that is).
Have been denied the first pre-auth, and 1st appeal. Going to the second one now and then I think that's it. However, now that the Prodisc is close to FDA final approval we can go through the whole thing again if the final appeal isn't approved.
Don't have any idea what the doctor's provide regarding appeals, but if you can submit your own paperwork, perhaps you can summarize with the fact that doctors submit that fusion puts additional stress on the levels immediately above and below the fusion. That the ADR will most likely prevent the progression of having to undergo additional surgeries, hospitalization as well as be a major factor in allowing you to remain actively employed. Dollar wise, depending on where you are located, if it saves BCBS from paying for say a 3 level fusion in the next couple of years, they could save themselves from paying a doctor about $60,000-70,000 in surgical fees and about that much more in hospitaliation, plus another $25,000 or more for the BMP that is used, and don't forget all the fees for other doctors involved in surgery, and that doesn't even count all the thousands they will pay out for additional MRI's and office visits, PT, etc leading up to the decision that more fusion is needed.
Since they are more about money than they are about helping people or even doing what is right, perhaps something along that line would get their attention. Best wishes for approval very soon.
that stinks. my l4-l5 adr was approved by hmo blue which is essentially the same company. they also approved blue cross blue shield from what my doc told me. i hope it works out for you. it was a great success for me. houston, texas
I, too, have a herniation/tear at L4/L5...I was denied twice by BC/BS for ADR. I am looking into a new device called the Wallis Implant. It is a spacer placed between the facet joints. The cost will be FREE since I would be part of a study. You may want to ask your doctor about it.