Re: Blue Cross Problem with Computer Assisted MIS Surgery

[Guest guest]

Of course it's worth appealing since you relied on their approval and

went ahead with the surgery.

I assume you have paperwork verifying the approval to go ahead.

In legal terms, you reasonably relied upon their having approved it

and they can't then deny payment -- that would be the argument.

This is quite different than an insurance company denying a benefit

prior to one having it -- although of course that can also be appealed

if important enough.

On Dec 9, 2008, at 3:13 PM, Hollie wrote:

> I hate this conservative Blue Cross. After they approved the surgery

> and I had it 8 weeks ago (Dr. Coon quad sparing), they write a letter

> saying they have completed a " retrospective review " .....and " Computer

> Assisted surg navigational procedures " are " investigational " and they

> are not covering this.

>

> Don't know how many dollars this amounts to.

>

> Has anyone else had this problems and is it worth it to appeal?

>

> Hollie

>

>

>

[Guest guest]

Oh, they EXPECT you to appeal and I know it will be a pain, but they will

even

explain in the denial letter exactly how to appeal. Write the letters, get

the

documentation, and you most likely will be approved on the second go.

You have to highlight the functional problems you were having before the

surgery,

how you had no other option, and chose a surgeon for his expertise, but had

no control over his choice of surgical procedures.

We can help you write the letters, I'm sure.

Good luck and keep us posted!

By the way, my surgeon here in Greenville, SC, also did a quad-sparing

technique this time (2008) as opposed to when he did my other knee in 2000.

Then because I am a PT he asked me if I could tell a difference in the

recovery and the rehab. Of course, the answer was a big YES and I told

him just how much better the recovery was! He says he now does the quad

sparing pretty routinely, as well as retaining the posterior cruciate

ligament.

Annie Pal

R TKR 2000

L TKR 2008

R TSR 2008

On Tue, Dec 9, 2008 at 6:13 PM, Hollie <rosey9932000@...> wrote:

> I hate this conservative Blue Cross. After they approved the surgery

> and I had it 8 weeks ago (Dr. Coon quad sparing), they write a letter

> saying they have completed a " retrospective review " .....and " Computer

> Assisted surg navigational procedures " are " investigational " and they

> are not covering this.

>

> Don't know how many dollars this amounts to.

>

> Has anyone else had this problems and is it worth it to appeal?

>

> Hollie

>

>

> ------------------------------------

>

>

[Guest guest]

Problem is solved, but you are absolutely right in that they should

not be able to deny payment once they approved it...hope that stands

up in court.

I called the doc and they are going to " eat " the cost since they are

in Blue Cross network. Blue Cross is also asking them for tons of

stuff and they send it again and again and Blue Cross says they

haven't received it.

So my problem is solved, but I simply hate Blue Cross.

Hollie

> Of course it's worth appealing since you relied on their approval

and

> went ahead with the surgery.

>

> I assume you have paperwork verifying the approval to go ahead.

>

> In legal terms, you reasonably relied upon their having approved

it

> and they can't then deny payment -- that would be the argument.

>

> This is quite different than an insurance company denying a

benefit

> prior to one having it -- although of course that can also be

appealed

> if important enough.

> On Dec 9, 2008, at 3:13 PM, Hollie wrote:

>

> > I hate this conservative Blue Cross. After they approved the

surgery

> > and I had it 8 weeks ago (Dr. Coon quad sparing), they write a

letter

> > saying they have completed a " retrospective

review " .....and " Computer

> > Assisted surg navigational procedures " are " investigational " and

they

> > are not covering this.

> >

> > Don't know how many dollars this amounts to.

> >

> > Has anyone else had this problems and is it worth it to appeal?

> >

> > Hollie

> >

> >

> >

>

>

>

>

[Guest guest]

Ann, can you tell me the name of the surgeon doing quad sparing in

SC? I have so many people asking me if I know of a surgeon near

them that does quad sparing, usually from back east or Ohio...we

need more surgeons doing this.

Yes, Blue Cross sucks. As I said above, the surgeon will " eat " the

cost because they are in network. But this shouldn't even happen.

Computer assisted surgeries for hips and knees and probably other

procedures, has become so common, I can't believe they would think

it " investigational " .

Thanks for your advice, I'll use it when I have an out of network

doc.

How did your recovery go? I'm walking fine at 8 weeks, 145 degrees

flexion, after no PT.

Hollie

> Oh, they EXPECT you to appeal and I know it will be a pain, but

they will

> even

> explain in the denial letter exactly how to appeal. Write the

letters, get

> the

> documentation, and you most likely will be approved on the second

go.

>

> You have to highlight the functional problems you were having

before the

> surgery,

> how you had no other option, and chose a surgeon for his

expertise, but had

> no control over his choice of surgical procedures.

>

> We can help you write the letters, I'm sure.

>

> Good luck and keep us posted!

>

> By the way, my surgeon here in Greenville, SC, also did a quad-

sparing

> technique this time (2008) as opposed to when he did my other knee

in 2000.

>

> Then because I am a PT he asked me if I could tell a difference in

the

> recovery and the rehab. Of course, the answer was a big YES and I

told

> him just how much better the recovery was! He says he now does

the quad

> sparing pretty routinely, as well as retaining the posterior

cruciate

> ligament.

>

> Annie Pal

> R TKR 2000

> L TKR 2008

> R TSR 2008

> On Tue, Dec 9, 2008 at 6:13 PM, Hollie <rosey9932000@...> wrote:

>

> > I hate this conservative Blue Cross. After they approved the

surgery

> > and I had it 8 weeks ago (Dr. Coon quad sparing), they write a

letter

> > saying they have completed a " retrospective

review " .....and " Computer

> > Assisted surg navigational procedures " are " investigational " and

they

> > are not covering this.

> >

> > Don't know how many dollars this amounts to.

> >

> > Has anyone else had this problems and is it worth it to appeal?

> >

> > Hollie

> >

> >

> > ------------------------------------

> >

> >

[Guest guest]

Hollie,

Have you mentioned this to Dr. Coon?

Mike

From: Hollie <rosey9932000@...>

Subject: Blue Cross Problem with Computer Assisted MIS

Surgery

Joint Replacement

Date: Tuesday, December 9, 2008, 3:13 PM

I hate this conservative Blue Cross. After they approved the

surgery

and I had it 8 weeks ago (Dr. Coon quad sparing), they write a letter

saying they have completed a " retrospective review " ..... and " Computer

Assisted surg navigational procedures " are " investigational " and they

are not covering this.

Don't know how many dollars this amounts to.

Has anyone else had this problems and is it worth it to appeal?

Hollie

[Guest guest]

I have Blue Cross and they covered my Computer Assisted Surgery for both of my

THRs.

what state are you in?  I am in California.

From: Hollie <rosey9932000@...>

Subject: Blue Cross Problem with Computer Assisted MIS

Surgery

Joint Replacement

Date: Tuesday, December 9, 2008, 3:13 PM

I hate this conservative Blue Cross. After they approved the surgery

and I had it 8 weeks ago (Dr. Coon quad sparing), they write a letter

saying they have completed a " retrospective review " ..... and " Computer

Assisted surg navigational procedures " are " investigational " and they

are not covering this.

Don't know how many dollars this amounts to.

Has anyone else had this problems and is it worth it to appeal?

Hollie

[Guest guest]

Yes, Dr. Coon's office will " eat " the cost since they are in Blue

Cross network. I still think this is outrageous for BC to do this.

Hollie

> Hollie,

>

> Have you mentioned this to Dr. Coon?

>

> Mike

>

>

> From: Hollie <rosey9932000@...>

> Subject: Blue Cross Problem with

Computer Assisted MIS Surgery

> Joint Replacement

> Date: Tuesday, December 9, 2008, 3:13 PM

>

>

>

>

>

>

>

>

>

>

>

> I hate this conservative Blue Cross. After they

approved the surgery

>

> and I had it 8 weeks ago (Dr. Coon quad sparing), they write a

letter

>

> saying they have completed a " retrospective review " .....

and " Computer

>

> Assisted surg navigational procedures " are " investigational " and

they

>

> are not covering this.

>

>

>

> Don't know how many dollars this amounts to.

>

>

>

> Has anyone else had this problems and is it worth it to appeal?

>

>

>

> Hollie

>

>

>

>

>

>

>

>

>

>

>

>

>

>

>

>

>

>

>

>

>

>

>

>

>

>

>

[Guest guest]

I'm in California too. I wonder what gives with Blue Cross,

sometimes they cover, sometimes they don't? Whoever heard of

a " retrospective " surgery review anyway.

Good for you that they covered it. I'm outside Sacramento, where

are you?

Hollie

> I have Blue Cross and they covered my Computer Assisted Surgery

for both of my THRs.

> what state are you in?  I am in California.

>

>

>

> From: Hollie <rosey9932000@...>

> Subject: Blue Cross Problem with

Computer Assisted MIS Surgery

> Joint Replacement

> Date: Tuesday, December 9, 2008, 3:13 PM

>

>

>

>

>

>

> I hate this conservative Blue Cross. After they approved the

surgery

> and I had it 8 weeks ago (Dr. Coon quad sparing), they write a

letter

> saying they have completed a " retrospective review " .....

and " Computer

> Assisted surg navigational procedures " are " investigational " and

they

> are not covering this.

>

> Don't know how many dollars this amounts to.

>

> Has anyone else had this problems and is it worth it to appeal?

>

> Hollie

>

>

>

>

>

>

>

>

>

>

>

>

>

>

>

>

>

>

>

[Guest guest]

Yes that 'retrospective' surgery review sounds a little fishy to me too! I know

I had to have a pre-authorization before I even entered the hospital. Blue Cross

knows what they are going to do before they do it. Just another example of

insurance companies trying to get out of paying!

 

I am down south in Orange County.

 

Good Luck! 

>

> From: Hollie <rosey9932000@ ...>

> Subject: [Total_Joint_ Replacement] Blue Cross Problem with

Computer Assisted MIS Surgery

> Total_Joint_ Replacement

> Date: Tuesday, December 9, 2008, 3:13 PM

>

>

>

>

>

>

> I hate this conservative Blue Cross. After they approved the

surgery

> and I had it 8 weeks ago (Dr. Coon quad sparing), they write a

letter

> saying they have completed a " retrospective review " .....

and " Computer

> Assisted surg navigational procedures " are " investigational " and

they

> are not covering this.

>

> Don't know how many dollars this amounts to.

>

> Has anyone else had this problems and is it worth it to appeal?

>

> Hollie

>

>

>

>

>

>

>

>

>

>

>

>

>

>

>

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