It appears you have not yet Signed Up with our community. To Sign Up for free, please click here....

Back Problems Message Board

ADR Denial/Appeal

Post New Thread   Closed Thread
LinkBack Thread Tools Search this Thread
Old 01-25-2006, 05:50 AM   #1
Junior Member
Join Date: Aug 2005
Location: Providence, RI
Posts: 30
RobinD21283 HB User
ADR Denial/Appeal

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.



Sponsors Lightbulb
Old 01-25-2006, 06:30 AM   #2
Senior Member
Join Date: Jan 2003
Posts: 274
go*big*red HB User
Re: ADR Denial/Appeal

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.

Again, good luck!
PLIF 3/03
2 level ACDF 10/03
Redo 10/04 & hdwr remove L5/S1
10/10/06 PLIF L4/5, Dynesys L3/4

Old 01-25-2006, 07:02 AM   #3
Join Date: Dec 2004
Posts: 1,291
Quietcook HB UserQuietcook HB User
Re: ADR Denial/Appeal


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.

Old 01-25-2006, 08:59 AM   #4
Join Date: Oct 2004
Posts: 333
jayboy557 HB User
Re: ADR Denial/Appeal

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

Old 01-26-2006, 07:42 AM   #5
Junior Member
Join Date: Sep 2005
Location: Indiana
Posts: 15
jaccrash HB User
Re: ADR Denial/Appeal

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.

Good luck!

Closed Thread

Similar Threads
Thread Thread Starter Board Replies Last Post
Letter of Denial mewcamaro Disabilities 8 01-23-2009 03:05 PM
Need Help - Just rec'd denial letter GracefulOne Disabilities 4 06-19-2008 01:25 PM
Letter of denial sickofpain2 Disabilities 9 05-06-2008 08:20 PM
SSD Law firm head called me about denial sickofpain2 Disabilities 4 05-06-2008 08:17 PM
How do I appeal BCBS Application Denial chrisp1027 Health Insurance - SSDI Issues 4 06-22-2007 06:08 AM
Hessie..............PT Denial ms_west Back Problems 0 04-04-2007 01:26 AM
Denial and Quality Review GinaS314 Disabilities 5 12-21-2006 11:24 AM
Blue Cross/Blue Shield denial of claim cartooner Health Insurance - SSDI Issues 6 02-10-2006 09:27 AM
Denial of benefits? Denial of appeal rights? hmogrief Health Insurance - SSDI Issues 2 03-01-2005 10:44 PM

Thread Tools Search this Thread
Search this Thread:

Advanced Search

Posting Rules
You may not post new threads
You may not post replies
You may not post attachments
You may not edit your posts

BB code is Off
Smilies are On
[IMG] code is Off
HTML code is Off
Trackbacks are Off
Pingbacks are Off
Refbacks are Off

Sign Up Today!

Ask our community of thousands of members your health questions, and learn from others experiences. Join the conversation!

I want my free account

All times are GMT -7. The time now is 09:50 AM.

Site owned and operated by HealthBoards.comô
© 1998-2018 HealthBoards.comô All rights reserved.
Do not copy or redistribute in any form!