RFA Denied by Insurance Final Appeal

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Retired Mom
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Date Joined Feb 2010
Total Posts : 1753
   Posted 4/26/2010 5:34 PM (GMT -6)   
Just an FYI to all who may be getting the RFA.  United has now DENIED them completely because they are considered "experimental" and "not proven".  I've filed all of my appeals and a Urologist (of all things) decided that it should not be approved.  Why a Urologist you may wonder.....well perhaps because they have no direct knowledge of a procedure for CP patients with serious back issues!!!  mad
Anyway, I wanted to give you all the heads up on this because mine WAS approved before it was done back in December and NOW I have been told that I have to pay for it all out of pocket. 
I don't want to see this happen to anyone else, so please beware if you have this insurance.  BTW, the procedure really did help me, so I'm sorry that I won't be able to have the last "set" of nerves done.
Best to you all!
Retired Mom

Veteran Member

Date Joined Nov 2007
Total Posts : 6795
   Posted 4/26/2010 6:07 PM (GMT -6)   
I am so sorry to hear that. And frustrated as well. Seems so unfair. I wonder how the PM's who do these procedures feel about it, as it's definitely going to affect their business. Does your doc's office have any other ideas as far as an appeal? Sometimes the billing people in doc's offices know some loopholes here and there. But you've probably already tried that.

I wish I had some better ideas.

PaLady shakehead

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Date Joined Jan 2010
Total Posts : 3557
   Posted 4/26/2010 8:12 PM (GMT -6)   
Boy..that stinks! It really is hard when insurance companies just change rules mid-stream with treatments...

Maybe you can work with your Dr.(the one who actually does the procedure) and since you have had this before and it did work, that if he contacts the company telling them this, that they will make an exception..

Unfortunately, the insurance only looks at the bottom line and stats...and it's not a very popular procedure anymore, so it becomes too expensive for them...

I am praying that you can either work it out somehow, or your Dr. finds some other modalities to help with your pain..

Sending you some hugs (( ))
SB and "the pup who snores loudly" 
ACDF C5-C7, (no hardware), with autograft bone Nov. 2001
(reabsorption of bone 2 years later...still lost in body..expect to burp it out at anytime..haha")) 
ACDF with hardware, allograft bone Nov. 2005 
Anterior and Posterior CDF, allograft bone with BMP, removal of old hardware, use of titanium plates, rods, screws, & kitchen sink (lol) Oct 2006

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Date Joined Aug 2006
Total Posts : 9664
   Posted 4/26/2010 8:20 PM (GMT -6)   
Maybe try to file an appeal, sorry you got denied..
keep us posted...
lots of soft hugz
* Asthma, Allergies, Osteoarthritis, Spinal Stenosis, Degenative Disc (Lower Lumbar S1-L3 and Cervical C5,C6, C8 and T1), Fibromyalgia, Gerd,
Enlarged Pituitary Gland, Sjogren's, Ocular Migraines, mild carpel tunnel, ect.... "Would be nice if we could use the edit button in real life"...


Retired Mom
Veteran Member

Date Joined Feb 2010
Total Posts : 1753
   Posted 4/26/2010 9:13 PM (GMT -6)   
eyes  Thanks for all of the suggestions.  I have actually exhausted all appeals and given my Dr. all of my paperwork so the he could "help" get it covered.  What I found out Friday was that when I told him about the insurance problem, he made a note in my chart that I could not have any more injections until I was released by my endo and removed from Human Growth Hormone treatment.  This will NEVER happen, as the treatments are forever.  We discussed this treatment fully at my appointment and he had no problem with anything....he even asked if I wanted to go back and get tble he nerves we were unable to do the last time.  That's when I told him about the insurance and he must have made the note.  He NEVER told me anyting about not doing any more injections until I was released or stopped my HGH meds.  The only way I found out was because I called them to see if I could come in for an injection to help with the nerve pain in the last facet joint because it had gotten really bad.  I have a walk-in/pick-up script tomorrow, but you don't see anybody but the receptionist then.  I just wanted an appointment before my next "real" one in three months.  That's when the nurse called me back and told me what the notes said.  I was shocked!
I'm starting to think this is just an "insurance won't pay so you won't get an injection" type of thing rather than a medical conflict thing.  All of my Dr's are completely aware of all medications and diagnoses I have been given and all have agreed on treatment paths.
This was really heartbreaking, but I'm afraid it's meds only from now on (unless something changes).  I just hope they won't do away with that.  Tomorrow may be a surprise UA and I have been using the Voltaren Gel of my husband's.  It was documented in all files, however, that I was to use it until it was gone and then any one of my Dr's would write a script for it if it worked (which it does quite well).  With the notes they have made, though, it makes you wonder what will happen next.
I'm not going to let myself borrow trouble tonight.  What will be will be and I'll have to deal with that when the time comes.
I just though you guys might need to know that they can go back and deny something that was already approved before the procedure because they have changed their minds. rolleyes
Retired Mom

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