Re: The Battle is Joined...

[Guest guest]

:

Have you recieved the first rejection letter? It should state the

methods of appeal open to you including review by the state

department of insurance (Outside review). I have been collecting

quite a bit of information about this but it's not ready to be

released on surface hippys. You can email me personally for further

discussion.

You need to analyse your contract provisions. What does it say

about medical necessity, provision of prosthetic devices and

participation in clinical trials. The Conserve + and the

cormet 2000 are bothe Invesigational Non-experimaental B-1 devices.

Their components have been approved for use individually (the

femoral component), and the acetabular component is essentially

similar to the M-O-M total hip devices which are already approved.

Depending on the wording of your policy, it might be argued that the

resurfacing devices are not " investigational in nature " . Will they

pay for unilateral resurfacing? You might be able to offer to pay

for the difference.

in NC

> (I just listened to a clip of Tony Blair speaking to his

government, and

> I love the way the British speak<G>) I thought I'd let you all

know my

> news.

>

> Not surprisingly, Anthem Blue Cross and Blue Shield of Louisville

KY,

> one of the Anthem Insurance Companies, Inc. has concluded my 'Blue

> Traditional ®' policy does not cover a BHR resurfacing in

Belgium,

> because it would not meet the medical necessity guidelines of the

plan,

> and is considered investigational in all cases.

>

>

[Guest guest]

At 06:42 AM 3/19/2003 +0000, you wrote:

>You need to analyse your contract provisions. What does it say

>about medical necessity, provision of prosthetic devices and

>participation in clinical trials.

Analyzing the wording in your contract and proving the contract will cover

your device is certainly one avenue. In my case, the contract was worded

that any investigational procedure or device would not be covered. I went

with convincing the insurance company that they would most likely pay out

much more for THR and subsequent care than they would to pay for

resurfacing. I used a friend of mine as a worst-case scenario, and the

results thus far have borne out. My insurance co. paid for both

resurfacings, less my co-pays. I was back to work two and 3 1/2 weeks post

op. Hers has paid for two THR's, a revision, a locking ring on one side, a

brace, multiple dislocations (12 thus far!), with both open and closed

reductions, and she is not done yet. She can no longer work, is on

disability, and is constantly worried about dislocating, so all activities

are severely limited. Anyone want to guess who has cost the insurance

company more so far??

C+ 5/25/01 and 6/28/01

[Guest guest]

ok Danz im in belgium waitin for Dr. De Sm to come by my rom at the holiday

inn and 8day post op and just walke through gent and had lunch with my

husband...it was a wonderful day here and i can only attest to this 7500 euro

for thehospital, 2500 to the surgeon and 500 to the anestheiologist. The

flight was 480 RT US and you really dont spend much after surgery cuz ya

cant....so im just thankful to have been able to do this and have had a great

trip! the cost for the holiday is is a discount 85 euro and the food is

cheap and amazing.

Sagliettigirl

[Guest guest]

ok Danz im in belgium waitin for Dr. De Sm to come by my rom at the holiday

inn and 8day post op and just walke through gent and had lunch with my

husband...it was a wonderful day here and i can only attest to this 7500 euro

for thehospital, 2500 to the surgeon and 500 to the anestheiologist. The

flight was 480 RT US and you really dont spend much after surgery cuz ya

cant....so im just thankful to have been able to do this and have had a great

trip! the cost for the holiday is is a discount 85 euro and the food is

cheap and amazing.

Sagliettigirl

[Guest guest]

ok Danz im in belgium waitin for Dr. De Sm to come by my rom at the holiday

inn and 8day post op and just walke through gent and had lunch with my

husband...it was a wonderful day here and i can only attest to this 7500 euro

for thehospital, 2500 to the surgeon and 500 to the anestheiologist. The

flight was 480 RT US and you really dont spend much after surgery cuz ya

cant....so im just thankful to have been able to do this and have had a great

trip! the cost for the holiday is is a discount 85 euro and the food is

cheap and amazing.

Sagliettigirl

[Guest guest]

dear sagliettigirl,

thanks for all the posts from ghent.

so you're using your laptop....does the hotel

have email/internet/computer access? i'm thinking

of bringing my laptop to while away the hours

but also thinking it's a bit of a bulky thing

to be hauling around and that being 'unplugged'

for a while might not be so bad.....

what types of exercises are you doing?

are you using the pool? steam room ? etc.

i'm on for april 2 with dr. de smet, and

wanting to make the most of all this.

cheers,

steph

april 2 rbhr de smet

[Guest guest]

dear sagliettigirl,

thanks for all the posts from ghent.

so you're using your laptop....does the hotel

have email/internet/computer access? i'm thinking

of bringing my laptop to while away the hours

but also thinking it's a bit of a bulky thing

to be hauling around and that being 'unplugged'

for a while might not be so bad.....

what types of exercises are you doing?

are you using the pool? steam room ? etc.

i'm on for april 2 with dr. de smet, and

wanting to make the most of all this.

cheers,

steph

april 2 rbhr de smet

[Guest guest]

: I agree with you completely. The relative lifetime cost of

the procedure compared to THR, including data from scientific papers

and websites should be included.

It also is important to cover multiple avenues of rejection by the

insurance company including conflicting statements in the policy

regarding coverage for " investigational procedures " , devices,

prothetics, clinical trials and otherreferences.

The details of each individuals case, degree of impairment, pain

levels, interference with life activities should be detailed and

supported with letters from physicians.

The details of the reasons for rejection as stipulated in the letter

from the insurance company need to be analysed and refuted point by

point.

in NC

>

> >You need to analyse your contract provisions. What does it say

> >about medical necessity, provision of prosthetic devices and

> >participation in clinical trials.

>

> Analyzing the wording in your contract and proving the contract

will cover

> your device is certainly one avenue. In my case, the contract

was worded

> that any investigational procedure or device would not be

covered. I went

> with convincing the insurance company that they would most likely

pay out

> much more for THR and subsequent care than they would to pay for

> resurfacing. I used a friend of mine as a worst-case scenario,

and the

> results thus far have borne out. My insurance co. paid for both

> resurfacings, less my co-pays. I was back to work two and 3 1/2

weeks post

> op. Hers has paid for two THR's, a revision, a locking ring on

one side, a

> brace, multiple dislocations (12 thus far!), with both open and

closed

> reductions, and she is not done yet. She can no longer work, is

on

> disability, and is constantly worried about dislocating, so all

activities

> are severely limited. Anyone want to guess who has cost the

insurance

> company more so far??

>

>

> C+ 5/25/01 and 6/28/01

[Guest guest]

Hi Danz, if you haven't read this one already, read message 8514

which I wrote quoting part of my approval letter (on 1st level of

appeal). Now it remains to be seen if they will actually pay for my

BHR as I recently got the bill from Belgium.

Isara

> (I just listened to a clip of Tony Blair speaking to his

government, and

> I love the way the British speak<G>) I thought I'd let you all

know my

> news.

>

> Not surprisingly, Anthem Blue Cross and Blue Shield of Louisville

KY,

> one of the Anthem Insurance Companies, Inc. has concluded my 'Blue

> Traditional ®' policy does not cover a BHR resurfacing in Belgium,

> because it would not meet the medical necessity guidelines of the

plan,

> and is considered investigational in all cases.

>

> Of course, I disagree, but that's the problem, isn't it?

>

> As many may know, I'm in the process of determining the costs of the

> alternatives to a De Smet/BHR resurfacing. I believe the facts will

> show the resurfacing a splendid bargain. Unfortunately, I've

discovered

> just how slippery the real facts about costs are to nail down. The

AMA

> apparently strictly controls availability of the guidelines used for

> fees, and there are several layers of nominal prices/costs, all

subject

> to limited scrutiny. What's more, precise statements of monies

actually

> spent are difficult to come by, too.

>

> I would like to request, again, that anyone who has not already

> mentioned their costs for non-BHR options please do so. I'll try to

> compile the info in a way that can be uploaded to the Surface Hippy

> files section--a kind of embryonic database of hospitalization

rejection

> ammunition for others to use in the future.

>

> I have been capturing particularly relevant messages in a separate

file

> for some time, now, planning to use the gems to formulate my plan to

> reverse the expected rejection. One area has been sadly neglected,

> because most correspondence that Surface Hippies have used in their

own

> successful campaigns has not made it into the archives of the forum-

-or,

> at least, I haven't seen it. Could I please request that folks send

> such letters to me by email, if they'd prefer to not put them into

the

> public eye, or perhaps post snippets or summaries of points,

tactics,

> etc. that seem to have had some positive effect. I would be happy

to

> add these to the files that I mentioned earlier, in appreciation.

>

> One reason I need this help is that if I must pay for my

resurfacing,

> too much of our savings against future emergencies will be eaten up

by

> the surgery and trip. I really need to succeed in convincing the

> insurance company it makes more sense to obtain resurfacing in

Belgium,

> than any of the more conventional alternatives. Your help will be

> greatly appreciated. TIA...

>

> danz

[Guest guest]

Hi Danz, if you haven't read this one already, read message 8514

which I wrote quoting part of my approval letter (on 1st level of

appeal). Now it remains to be seen if they will actually pay for my

BHR as I recently got the bill from Belgium.

Isara

> (I just listened to a clip of Tony Blair speaking to his

government, and

> I love the way the British speak<G>) I thought I'd let you all

know my

> news.

>

> Not surprisingly, Anthem Blue Cross and Blue Shield of Louisville

KY,

> one of the Anthem Insurance Companies, Inc. has concluded my 'Blue

> Traditional ®' policy does not cover a BHR resurfacing in Belgium,

> because it would not meet the medical necessity guidelines of the

plan,

> and is considered investigational in all cases.

>

> Of course, I disagree, but that's the problem, isn't it?

>

> As many may know, I'm in the process of determining the costs of the

> alternatives to a De Smet/BHR resurfacing. I believe the facts will

> show the resurfacing a splendid bargain. Unfortunately, I've

discovered

> just how slippery the real facts about costs are to nail down. The

AMA

> apparently strictly controls availability of the guidelines used for

> fees, and there are several layers of nominal prices/costs, all

subject

> to limited scrutiny. What's more, precise statements of monies

actually

> spent are difficult to come by, too.

>

> I would like to request, again, that anyone who has not already

> mentioned their costs for non-BHR options please do so. I'll try to

> compile the info in a way that can be uploaded to the Surface Hippy

> files section--a kind of embryonic database of hospitalization

rejection

> ammunition for others to use in the future.

>

> I have been capturing particularly relevant messages in a separate

file

> for some time, now, planning to use the gems to formulate my plan to

> reverse the expected rejection. One area has been sadly neglected,

> because most correspondence that Surface Hippies have used in their

own

> successful campaigns has not made it into the archives of the forum-

-or,

> at least, I haven't seen it. Could I please request that folks send

> such letters to me by email, if they'd prefer to not put them into

the

> public eye, or perhaps post snippets or summaries of points,

tactics,

> etc. that seem to have had some positive effect. I would be happy

to

> add these to the files that I mentioned earlier, in appreciation.

>

> One reason I need this help is that if I must pay for my

resurfacing,

> too much of our savings against future emergencies will be eaten up

by

> the surgery and trip. I really need to succeed in convincing the

> insurance company it makes more sense to obtain resurfacing in

Belgium,

> than any of the more conventional alternatives. Your help will be

> greatly appreciated. TIA...

>

> danz

[Guest guest]

Hi Danz, if you haven't read this one already, read message 8514

which I wrote quoting part of my approval letter (on 1st level of

appeal). Now it remains to be seen if they will actually pay for my

BHR as I recently got the bill from Belgium.

Isara

> (I just listened to a clip of Tony Blair speaking to his

government, and

> I love the way the British speak<G>) I thought I'd let you all

know my

> news.

>

> Not surprisingly, Anthem Blue Cross and Blue Shield of Louisville

KY,

> one of the Anthem Insurance Companies, Inc. has concluded my 'Blue

> Traditional ®' policy does not cover a BHR resurfacing in Belgium,

> because it would not meet the medical necessity guidelines of the

plan,

> and is considered investigational in all cases.

>

> Of course, I disagree, but that's the problem, isn't it?

>

> As many may know, I'm in the process of determining the costs of the

> alternatives to a De Smet/BHR resurfacing. I believe the facts will

> show the resurfacing a splendid bargain. Unfortunately, I've

discovered

> just how slippery the real facts about costs are to nail down. The

AMA

> apparently strictly controls availability of the guidelines used for

> fees, and there are several layers of nominal prices/costs, all

subject

> to limited scrutiny. What's more, precise statements of monies

actually

> spent are difficult to come by, too.

>

> I would like to request, again, that anyone who has not already

> mentioned their costs for non-BHR options please do so. I'll try to

> compile the info in a way that can be uploaded to the Surface Hippy

> files section--a kind of embryonic database of hospitalization

rejection

> ammunition for others to use in the future.

>

> I have been capturing particularly relevant messages in a separate

file

> for some time, now, planning to use the gems to formulate my plan to

> reverse the expected rejection. One area has been sadly neglected,

> because most correspondence that Surface Hippies have used in their

own

> successful campaigns has not made it into the archives of the forum-

-or,

> at least, I haven't seen it. Could I please request that folks send

> such letters to me by email, if they'd prefer to not put them into

the

> public eye, or perhaps post snippets or summaries of points,

tactics,

> etc. that seem to have had some positive effect. I would be happy

to

> add these to the files that I mentioned earlier, in appreciation.

>

> One reason I need this help is that if I must pay for my

resurfacing,

> too much of our savings against future emergencies will be eaten up

by

> the surgery and trip. I really need to succeed in convincing the

> insurance company it makes more sense to obtain resurfacing in

Belgium,

> than any of the more conventional alternatives. Your help will be

> greatly appreciated. TIA...

>

> danz