Re: Insurance Appeal Advice Needed!

[Guest guest]

Ken,

I hope someone has better news for you as my experience on the insurance

front with Blue Cross is not good. I've fought Blue Cross of CA for a

couple of years for my second resurfacing. They covered my left 2/98 C+

resurfacing when I was pre-trial but have since changed all their policies

not to cover experimental surgeries. I’m not certain if there’s a

connection between CareFirst Blue Cross and Blue Cross CA, but suspect

you’re in the same boat. The C+ is awaiting FDA approval, and the best

guess for their decision is sometime late this year. There’s no guarantee,

but again, the best guess is it will be approved.

I made excellent appeals but they fell on deaf ears, both at BlueCross and

the State regulatory agency. I’ve talked to a couple of attorneys, in

addition to my attorney son, who tell me I have a good case legally

considering I was previously covered. But realistically a lawsuit would

take more time than the expected FDA approval. I’m in a group plan that

falls under more pro-insurance Federal laws. I’m told that individual plans

fall under more patient friendly state law, California in my case. I know

some patients pay for it out of pocket then enlist an attorney to fight for

insurance on a contingency basis. I know of one class action suit against

Blue Cross CA that's going on, but I've yet to hear of anyone successfully

getting an insurance denial overturned in the US.

At the end of the day I was left with three options: (1) wait for FDA

approval which makes it covered by insurance, (2) paying $30K- $35K

out-of-pocket, or (3) having the same ball and socket as the C+ but attached

to a titanium stem in a THR - Blue Cross covers THR’s.

Doctors were concerned that my right hip was deteriorating so much that if I

waited, it might be too far gone for resurfacing, and my quality of life was

steadily diminishing, so my choices were limited to (2) and (3). The

Technologies Conserve THR was looking like a good second option to the C+

resurfacing, and I was seriously entertaining it until I came up with a way

to swing the C+ resurfacing.

I didn’t get much help from the FDA - there’s not a whole lot of help out

there, but these two were the most knowledgeable:

http://www.wmt.com/bigfemoralhead/default.asp and Chuck of JRI,

http://www.jri-oh.com/.

I hope this helps. Best of luck,

Dave G.

C+ Dr. Amstutz of JRI, 02/98, 3/12/04

>

>Reply-To: surfacehippy

>To: surfacehippy

>Subject: Insurance Appeal Advice Needed!

>Date: Mon, 22 Mar 2004 15:17:56 -0000

>

>Hi All:

>

>I sit here writing you this morning (March 22nd)instead of having my

>just cancelled hip resurfacing surgery. I was scheduled with Dr.

>Mont this morning, but found out to my chagrin 11 days ago that

>CareFirst Blue Cross/Blue Shield of land did not cover the

>procedure. This was particularly painful news as my surgery had

>already been postponed last December and January due Dr. Mont's FDA

>issues noted in prior posts.

>

>I am asking anyone who has successfully obtained pre-authorization

>for hip resurfacing surgery after initial denial by CareFirst, if

>they would be willing to contact me offline. Any clues as to how to

>proceed in an appeals process would be greatly appreciated. If I

>cannot reverse this decision I will have to endure this discomfort

>until early next year,at which time I can switch my insurance

>coverage to Aetna. Right now, this prospect is too much to

>contemplate.

>

>Thanks in advance for your advice.

>

>Ken

>

>

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[Guest guest]

Hi Ken,

Sorry to hear about your cancellation. That is cruel! I don't

understand coz I was approved the first time (see my msg #22310).

Did Mont's office made the request for you? They may be able to help

with your appeal anyway, coz they mentioned something like that to me

when I asked about possible refusal.

You may not have to wait a full year if FDA approval happens this

fall. Hopefully other hippies will have better advice. There have

beeen many postings about appeals. Search the archives.

Good luck.

Ed

Mont RC+ Nov '03

> Hi All:

>

> I sit here writing you this morning (March 22nd)instead of having

my

> just cancelled hip resurfacing surgery. I was scheduled with Dr.

> Mont this morning, but found out to my chagrin 11 days ago that

> CareFirst Blue Cross/Blue Shield of land did not cover the

> procedure. This was particularly painful news as my surgery had

> already been postponed last December and January due Dr. Mont's FDA

> issues noted in prior posts.

>

> I am asking anyone who has successfully obtained pre-authorization

> for hip resurfacing surgery after initial denial by CareFirst, if

> they would be willing to contact me offline. Any clues as to how

to

> proceed in an appeals process would be greatly appreciated. If I

> cannot reverse this decision I will have to endure this discomfort

> until early next year,at which time I can switch my insurance

> coverage to Aetna. Right now, this prospect is too much to

> contemplate.

>

> Thanks in advance for your advice.

>

> Ken

[Guest guest]

Hi Ken:

Depending on deductibles and copays (if you get

approval), it may still be more expensive than or

similar to the cost of going to Belgium. I'd look

into those numbers. Besides, you can't do better than

DeSmet.

Tom

DeSmet RBHR 11/03

--- Ken profks@...> wrote:

> Hi All:

>

> I sit here writing you this morning (March

> 22nd)instead of having my

> just cancelled hip resurfacing surgery. I was

> scheduled with Dr.

> Mont this morning, but found out to my chagrin 11

> days ago that

> CareFirst Blue Cross/Blue Shield of land did not

> cover the

> procedure. This was particularly painful news as my

> surgery had

> already been postponed last December and January due

> Dr. Mont's FDA

> issues noted in prior posts.

>

> I am asking anyone who has successfully obtained

> pre-authorization

> for hip resurfacing surgery after initial denial by

> CareFirst, if

> they would be willing to contact me offline. Any

> clues as to how to

> proceed in an appeals process would be greatly

> appreciated. If I

> cannot reverse this decision I will have to endure

> this discomfort

> until early next year,at which time I can switch my

> insurance

> coverage to Aetna. Right now, this prospect is too

> much to

> contemplate.

>

> Thanks in advance for your advice.

>

> Ken

>

>

>

[Guest guest]

> Hi All:

>

> I sit here writing you this morning (March 22nd)instead of having

my

> just cancelled hip resurfacing surgery. I was scheduled with Dr.

> Mont this morning, but found out to my chagrin 11 days ago that

> CareFirst Blue Cross/Blue Shield of land did not cover the

> procedure. This was particularly painful news as my surgery had

> already been postponed last December and January due Dr. Mont's

FDA

> issues noted in prior posts.

>

> I am asking anyone who has successfully obtained pre-authorization

> for hip resurfacing surgery after initial denial by CareFirst, if

> they would be willing to contact me offline. Any clues as to how

to

> proceed in an appeals process would be greatly appreciated. If I

> cannot reverse this decision I will have to endure this discomfort

> until early next year,at which time I can switch my insurance

> coverage to Aetna. Right now, this prospect is too much to

> contemplate.

>

> Thanks in advance for your advice.

>

> Ken dear ken i'm in the same boat,however you might check with

dr stachinew in ill. let me know what transpires although i've

pretty much decided to go to desmet art 8314257864,831 2472621 .