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Anyone deal with Blue Cross in NY?

AnonymousUserAAnonymousUser Posts: 49,671
edited 06/11/2012 - 8:31 AM in Back Surgery and Neck Surgery
I am slated to have a TDR (ProDisc) L4-L5 and fusion L5-S1 next week and am waiting for approval from Blue Cross. So far it has been deemed experimental by BCBS but I am hoping to convince them. Has anyone had BCBS approve the TDR in NY if so I would like to get in contact, for if I can show that they have approved it before then they will be less likely to deny mine. Also if anyone has had a positive outcome from TDR that would be great to hear since it seems most people only write about the horror stories and I'm scared to death as it is!

herniated L4-L5/ L5-S1 in 2002 loading an airplane in the AF(VA won't touch TDR)
positive discogram (discs are mush), no previous surgeries but lots of PT/ Chiro/ Accupuncture/ meds/ TENS/ massage from loving husband


  • I had BCBS in NY. I can't remember if it was for southern tier or Syracuse. I was denied TDR even after 5 years of conservative treatments and appealed all the way up to the NY State Insurance dept but was unable to get approval. I did research on this and was informed that they have never approved the TDR. I wrote several letters but they continued to deny based on investigational/experimental reasons.

    In my personal opinion, had they approved this surgery, my recovery would be much better than what I am dealing with now.

    I am not on medicaid cuz I was out of work for so long due to disability and lost my job of 11+ years and couldn't afford COBRA.

    There has to be a first to be approved eventually since this is becoming more common and I wish you the best of luck. I'm sorry I didn't have more positive info to provide.
  • jlrfryejjlrfrye ohioPosts: 1,110
    I do medical billing for a living and getting bcbs to pay for a procedure that is considered experimental is impossible.My suggestion to you is get a copy of the contract and go through it to find a loop hole. Believe it or not there have been patients able to do this and have their claims reimbursed, dealing with insurance can be very frustrating so if there is anything i can do to help you please feel free to pm me. I deal with insurance companies on a daily basis and know that most patients do not know the proper channels to get a resolution to an unpaid claim. The last thing all of us with daily pain need is the added stress of insurance issues so if I can help you or anyone else feel free to pm
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