Re: Whoo-hoo to Jim---CIGNA Paid for 75%

June 26, 2004

Resedamickey,

I'm covered under my wife's plan--CIGNA PPO (an ERISA plan). She's

an AT&T retiree.

As I said in in my previous post (last Wed, 6/23, Msg No.

28599), " CIGNA...denied Dr. Beaulé's [JRI's]...request for pre-

authorization to resurface my left hip—-and they twice denied my

subsequent appeals. "

My claim included the following documents:

1) Cover letter summarizing all costs included in my claim

2) CIGNA Health Insurance Claim Form listing all claimed costs

(available at CIGNA's web site)

3) Jan Palfijn Hospital bill (untranslated, in Flemish)

4) Copy of Jan Palfijn Hospital bill (translated into English)

5) Health insurance claim form for Dr. De Smet's fee (completed &

signed by Dr. De Smet)

6) Holiday Inn Gent receipt for 5 nights lodging during Dr. De Smet's

required medical recovery period

7) BVBA ANCA receipt for wound treatment and physical therapy at

Holiday Inn Gent (signed by Dr. De Smet)

8) BVBA Zircone receipt for Dr. De Smet's administration costs

(signed by Dr. De Smet)

9) Copy of Visa statement confirming I paid Jan Palfijn Hospital

fee and Holiday Inn Gent bill

10) Copy of Schwab statement confirming I wired surgeon's fee,

BVBA ANCA payment, and BVBA zircone payment

11) Copy of Schwab deposit receipt showing I received Jan Palfijn

Hospital refund

AT&T did not help with anything.

CIGNA said they denied JRI's request and my two appeals because the

resurfacing device is investigational. Of course, BHR isn't

investigational where it's performed...

Jim V.S.

LBHR, De Smet, 11/25/03

> Jim - what company do you work for? Do you have CIGNA HMO

> or POS or ERISA?

> Did you have to go through levels of appeal?

> What docs did you submit?

> Did your company help?

> Did they originally turn you down because of the JRI codes and

> then pay because JRI returned to THR codes?

June 26, 2004

Jim...

Your last line makes everything else completely clear. Of course,

the BHR would not be considered investigational by the FDA. It's

already approved for use in the places where it's installed, or they

wouldn't be installing it. (Apparently) A worrisome question: If

JRI, for instance decided to start branching out to use BHR...would

the device then become " investigational " here and subject to the same

insurance resistance? But geez...that makes it seem like Belgium

just became a no-brainer for anybody who gets any insurance

resistance in the U.S.

Thank you.

Alan

> CIGNA said they denied JRI's request and my two appeals because the

> resurfacing device is investigational. Of course, BHR isn't

> investigational where it's performed...

>

> Jim V.S.

> LBHR, De Smet, 11/25/03

>

June 26, 2004

Hi Alan,

Your question is really: Would the BHR device have to go through the

same hoops that the C+ and C2K are going through to get FDA

approval? I don't know, but my opinion is that it shouldn't have to

since it has a much longer track record than either the C+ or the

C2K. For a better perspective on such a notion, perhaps we should

turn to Brewster (the closest thing we have to an FDA expert on

Surfacehippy) for an answer...

Anyway, my main message to any and all prospective surfacehippies is

that if money is a concern (e.g., insurance coverage is a problem),

Belgium is, as you say, " a no-brainer. " It certainly was for me...

BTW, I'm heading out this afternoon to play tennis for 1st time since

my surgery. Although I've been playing racquetball for four months

now (i.e., I've been practicing by myself 30-45 min once a week),

I'll need to " fire up " for this outing since my opponent is a 23 yr

old, 6'1 " , 230 lb " kid " who happens to be a national caliber

racquetball player and bench presses 495 lb (I'm 55, 5'11 " , 160 lb).

It should be fun...i.e., if I don't get nailed by any of his shots.

Jim V.S.

LBHR, De Smet, 11/25/03

> Jim...

>

> Your last line makes everything else completely clear. Of course,

> the BHR would not be considered investigational by the FDA. It's

> already approved for use in the places where it's installed, or

they

> wouldn't be installing it. (Apparently) A worrisome question: If

> JRI, for instance decided to start branching out to use BHR...would

> the device then become " investigational " here and subject to the

same

> insurance resistance? But geez...that makes it seem like Belgium

> just became a no-brainer for anybody who gets any insurance

> resistance in the U.S.

>

> Thank you.

> Alan

>

> > CIGNA said they denied JRI's request and my two appeals because

the

> > resurfacing device is investigational. Of course, BHR isn't

> > investigational where it's performed...

> >

> > Jim V.S.

> > LBHR, De Smet, 11/25/03

> >

June 26, 2004