wanted to share MY insurance definitions and thoughts

[symara]

Ok, so I read the Insurance Warrior's book and was looking at my definition for what will probably come with my denial (I work for my insurance compnany)

It will be denied experimental and investigational so according to my plan it has this definition:

Experimental, investigational or for research purposes

:
means a drug, biological product, device,

treatment or procedure that meets any one of the following criteria as determined by the


Plan Manager:

1. Is identified as not covered by the Health Care Finance Administration Medicare Coverage Issues
Manual as experimental;
2. Cannot be lawfully marketed without the final approval of the United States Food and Drug
Administration (FDA) and which lacks such final FDA approval for the use or proposed use, unless
1) it is found to be accepted for that use in the most recently published edition of the United States
Pharmacopeia-Drug Information for Healthcare Professionals (USP-DI) or in the American Hospital
Formulary Service (AHFS) Drug information, or 2) it is identified as widely used and generally
accepted as effective for the proposed use as reported in a national database of peer reviewed medical
literature published in the English language as of the date of service;
3. Is a device required to receive Premarket Approval (PMA) or 510K approval by the FDA but has not
received a PMA or 510K approval;
4. Is not identified as widely used and generally accepted as effective for the proposed use as reported in
a national database of peer reviewed medical literature published in the English language as of the
date of service; or
5. Is subject of a Phase I trial or is otherwise under study to determine its maximum tolerated dose, its
toxicity, or its safety.


I will address each one and tell me what you think...


1. Medicare has only addressed the issue for those over 60, right? so this does not pertain to me since I am 30.


2.N/A - FDA approved


3. N/A


4. I just need to get some peer reviewed articles, right? What has everyone else used? What is suggested?


5. N/A

[dshobbies]

Can't say for sure but #4 may be the legal kicker.

It's very definitely worth a try but for every article you find, I bet your ins. co has 10 that contradict it. But go for it!

[Dulishun]

Actually as one who has been recently rejected by United Healthcare, I can tell you that they do not have counter studies, but rather suggest deficiencies in the same studies referenced by companies like Aetna who approve it. Examples are that there were not enough participants, etc. The entire basis for the United Healthcare rejection is that the FDA did not give express approval, but only approved it in lieu of 5 year data to be provided by the prosthetic manufacturer (in my case Synthes). If anyone wants all of the documentation that the insurance company relies on I have it as they were compelled to provide it to me on request. Just let me know and I can fax it to you.

-----------------------------------------------------------------------------
L5S1 Herniation and Annular tear
Over 10 epidurals,
DDD, 2 discograms (positive),
Countless attempts at conservative therapy.
Surgery date 5-26-09

[symara]

i would love it, but I don't have a personal fax, just a work fax, and that may not look good if someone else sees it.

[Dulishun]

Check your messages. Hate to bore everyone with the particulars of scanning, etc.!

-----------------------------------------------------------------------------
L5S1 Herniation and Annular tear
Over 10 epidurals,
DDD, 2 discograms (positive),
Countless attempts at conservative therapy.
Surgery date 5-26-09

[Alynn]

Dulishun:
I sent you an email requesting the UHC documentation.

Thanks,
Alynn

[adamarisclark]

Hi,

I am new here to this forum. My name is Adamaris Clark. I live in UK and working with theppiclaims. I am here to learn and view my express with each other. The information shared in this post is impressive and good.