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Insurance Precedent

pamelabppamelab Posts: 1
edited 01/30/2013 - 8:37 AM in Back Surgery and Neck Surgery
I am new to the forum. I have cervical DDD levels c4/5 through c7/t1. I had a multi-level ADR by Dr. EDIT in September 2011 and have been thrilled with the results. Initially my insurance company paid the claim but is now rescinding that and demanding I return all monies paid, as the multi-level ADR is deemed experimental. I am looking for any cases where insurance has paid for a multi-level cervical ADR, whether in the United States or abroad. I read somewhere that BSBC has paid for military but I cannot find that information anywhere. I appreciate your help.

Post edited. Forum rules prohibit the naming of specific doctors.


  • kamgramkkamgram Posts: 483
    edited 01/30/2013 - 7:44 PM
    You surgeons office should have gotten the surgery approved before they did the surgery then there would have been no reason to want payback. Prehaps your doctors office worded it different and this was approved by insurance but then when they seen surgery notes they realized this is not what they were told. Perhaps your surgeon got in there and decided he needed to chnage procedure. I would check with insurance and see what the problem is and then call surgeon's billing office and have a talk with them. I know working in doctors office and having BCBS at one time they have done this to me but not for major back surgery. Good luck and let us know how it turns out.

  • I don't think they have a chance on getting you to reimburse them for a surgery they approved.
    They might against the doctors insurance.

    Don't loose any sleep over it.

    L4/5 herniation13mm sequestered fragment L5 root compromise.
    L3/4 annular tear.
    L2/3 3mm bulge and annular tear.
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    Epidural L4 L5 28Nov12 / 12Dec12 / 26Dec12. All no relief :( SO FAR
    MicroD L4 L5 May 23 2013
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  • jlrfryejjlrfrye ohioPosts: 1,111
    A approval is not a guarantee of payment. I bill insurance for a living for Drs.. and I have seen this happen more then once. Somewhere is your contract this particular surgery is listed as experimental. Contact your surgeons office and see if they can use a different procedure code to send a corrected claim to avoid the surgery being unpaid. As for the Drs payment they will do a take back on the claim and use the money to pay another claim, so it doesnt matter if your Dr. agrees to this or not the money will come out of a future check owed to him. Trust me your Drs. office will everything they can to get this paid and if they dont PM and I will help you thru the appeal process
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