Upcoming surgery w/Dr Zeegers

[vnf]

Henry

When I called BCBS Worldwide, I told them that I was going for a planned surgery and would I have any benefits for that.
The guy asked me for my member # and said "yes, I do have benefits".
I specifically said "even though it's a planned surgery and I'm not there vacationing and something accidental happens". The guy said yes, I have benefits but a pre authorization has to be done by the clinic.
The guy gave me a case number and I'm supposed to call them back when I have a surgery date. That's as far as I've gone.
I have not called back yet to see what happens next.
I know that just because he says "I qualify for benefits" doesn't mean that they will approve anything.
I'm going to try and get it covered too.
I'm pretty much feeling like US or Germany won't matter and they will still try to deny it for any reason they want to dig up.
I hate them! It's very frustrating.

[henry4956]

Got my 1st official denial today. It was on the basis of not meeting 'medical necessity' criteria. I actually think I will eventually win. If their denial was based on the 'experimental' explanation I would be more discouraged.

[Jim M2]

For sure this is David vs Goliath. David won. I think you will too.

I hope you can get a spine surgeon to write the letter. No doubt that would help. I'm sure I've posted my letter before but here it is just in case you can't find it. I don't know if it will be useful. Several weeks after my surgery I submitted a written appeal (SEE THE LETTER BELOW THE ASTERICKS) requesting to be reimbursed for medical costs. About 50 pages of doctors office notes, radiology reports and all of the bills and descriptions of services from Germany (and in German) were attached to the appeal. Several weeks later I received a check for 89% of the total.

Consider that my employer, not Regence, is the risk taker in my plan. Regence was hired to simply administer the plan. In the end I think the real decision to approve the appeal was made by company management. What were their motives? I don't know, but somehow I feel it wasn't just a bottom line decision. I've found the company to be reasonably fair in these matters. No telling what you're dealing with. I think your Goliath is bigger than my Goliath. The bigger they are the harder they fall.

************************
October 24, 2003

Regence Blue Shield
address
Seattle, WA

Dear Appeals Specialist,

PUPPOSE
I am appealing to Regence Blue Shield and The Company to reimburse me for medical costs of artificial disc replacement (ADR) that were incurred in August and September of 2003 in Munich, Germany. Please respond to this request in writing to the undersigned.


INTRODUCTION
In May 2002 I developed chronic, severely debilitating low back pain. In search of relief I visited numerous physicians including a pain management doctor, orthopedic surgeons and neurosurgeons. MRI, X-rays and CAT-Myelo diagnostics all confirmed a collapsed lumbar disc at L5S1. Medications, physical therapy, exercise and severe restriction of activities brought only limited reduction in pain levels. After months of research on the topics of spinal disorders, fusion and ADR I opted for ADR. In August 2003 I traveled to Munich, Germany and had ADR by Dr. Willem Zeegers at the Alpha Clinic.

LETTER OF MEDICAL NECESSITY
I am submitting this letter together with the writings of five surgeons as a Letter of Medical Necessity.

The first three writings are office notes from the U.S. surgeons who personally examined me in 2002 and 2003 prior to surgery. Their names are Dr. Villanueva, Dr. Schlitt and Dr. Krengel. Their office notes are attached. All three surgeons speak of spinal fusion as the primary option to be considered in my case for pain reduction and increased functionality if conservative treatment did not improve my condition.

The forth writing is from Dr. ML Whitworth. His writing is a matter of public record. It can be found online at the Massachusetts General Hospital Neurology discussion forum. A copy is attached. Dr. Whitworth feels "fusion is an archaic barbaric anachronism which is only necessary if there is significant spondylolisthesis or foraminal stenosis..." In the attached writing he goes on to justify this statement, to advocate ADR under protocol and to explain that many surgeons continue to perform fusions for monetary reasons.

The fifth writing is a diagnostic report on my condition from Dr. Zeegers of the Alpha Clinic in Munich, Germany. Dr. Zeegers is the world's leading ADR surgeon. He has performed over 1000 implant surgeries since the 1980s. After examining my MRI, CAT-Myelo, x-rays, radiology reports and patient questionnaire he concluded that I was a good candidate for ADR, pending a personal examination in Munich.

Beyond these writings I read extensively on the topics of spinal disorders, spinal fusion and ADR to ascertain my understanding of the risks and potential benefits of these two medical procedures. My conclusion matched that of Dr. Whitworth and Dr. Zeegers. It was my conclusion that ADR was statistically superior to fusion for pain reduction, improved functionality and better prospects for long term health.

ADDITIONAL CONSIDERATIONS
1) ADR at Alpha Clinic costs $20K. It is my understanding that ADR under FDA trials in the U.S. costs $60K. It is my understanding that costs for spinal fusion in the U.S. range from $50K to $80K.

2) Dr. Zeegers is the world's leader in ADR. He has performed over 1000 implants of the SB Charite artificial disc since the 1980s.

3) Surgery was needed in the near term to relieve pain, prevent degeneration of facet joints and to eliminate potential for nerve damage.

4) It stands to reason that European surgeons performing ADR would have a higher success rate when compared to their lesser experienced U.S. counterparts.

MEDICAL ACTIVITIES AT ALPHA KLINIK
On 18-Aug-2003 I departed for Munich, Germany. On 21-Aug-2003 I was personally examined by dr. Zeegers at the Alpha Clinic. X-rays were made of the lumbar spine and discography was performed on levels L2S1. A complete physical examination which included chest x-ray, EKG, breathing and blood test, was performed. I was fitted with a custom made lumbar corset. On 22-Aug-2003 a Charite artificial disc was implanted at the L5S1 level of my spine. I spent four nights in the Alpha Clinic hospital before being released on 26-Aug-2003. Just prior to release from the clinic more x-rays were taken to verify placement of the implant. An ultrasound test was conducted to verify the absence of thrombosis. In the two weeks after surgery I received two more personal examinations by Dr. Zeegers and five sessions of physical therapy at the Alpha Clinic.


SUMMARY OF MEDICAL CHARGES AND PAYMENTS
Receipts, exchange rates, accounting and descriptions of services are attached. Payments were made by wire transfer and VISA card. Approximately $6K of travel expenses and lodging have been borne by myself.

CHARGES
ITEM EURO
Brace Shop 1,000.00
Anesthesiology 1,540.66
Medical Exam 300.00
Alpha Clinic 10,389.90
Surgeon 4,371.52
Ultrasound 88.27
Physical Therapy* 450.70
-------------------------
Total 18,141.05

PAYMENTS
ITEM EURO US DOLLAR
Wire Transfer 15,256.97 17,250.00
VISA 1,000.00 1,101.76
VISA 1,345.11 1,481.98
VISA 88.27 97.25
VISA* 350.56 393.34
VISA* 90.14 101.14
-------------------------------------
Totals 18,131.05 20,425.47

*Discrepancy between charges and payments for physical therapy appears to be a clerical error where Alpha Klinik billed my VISA 350.56 Euro instead of 360.56 Euro.

CONCLUSION
Regence BS and The Company are requested to pay $20,425.47 to employee "First M. Last" to meet their obligations as his health care provider. Please respond to this request in writing to the undersigned.

Sincerely,
First M. Last

Contact information:

[henry4956]

Thanks much Jim, I did submit a 'Letter of Medical Necessity' that Dr Zeegers filled out. It was not elaborate but he spoke of my unbearable suffering. I am reaching out to my local neurosurgeon who had been treating me for 2 years prior to surgery. I have already obtained all of his notes for the injections he performed on me. I was hoping that in those notes from my last visit to him prior to my surgery that he would have mentioned that I could not stand for more than 5 minutes and I had regressed greatly. He also said the 'the time had come to do something'. He did not mention those things in his notes. In my letter to him I reminded him of my dire condition and also that he told me fusion surgery would be a 50/50 proposition for quality of life. I just sent it to him today. I sure wish he had taken the time to make those notes when I was there. I will be very upset if he doesn't write a letter stating my condition. My wife works at RI Hospital and she is the administrative assistant to the man who has the power to make a call and fix this wrong. He told her yesterday to go thru the appeal process and if denied again he will get involved.

[Jim M2]

It good you have someone with some weight who can pull for you if the appeal doesn't work.

[susadr]

Hi henry4956,

How do you feel almost a year post ADR surgery? I'm eager to hear how you feel about your Activ-L ADR!