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Thread: United Health Care Insurance - denied coverage

  1. #1
    Join Date
    May 2012
    Location
    El Centro, CA & Baja California, Mexico
    Posts
    193

    United Health Care Insurance - denied coverage

    I just got a call from Dr Bridwell's office that they just received a 25page memo on covering BMP in any spinal surgery. That if it is used, the entire operation will be denied not only the use of the BMP.

    So my date of Oct 16th is on hold until Dr Bridwell finds a solution. Apparently, BMP has worked very well with lots of success and he does not feel that I would do well by not using it.

    Anyone else had this happen? Does other insurances cover BMT?

    Needless to say, I am devastated. BMP cost about $100k

    Gardenia
    Gardenia
    Baja California, Mexico & El Centro, Ca
    pre-surgery 75 and 89 - post ?
    Dr. Bridwell Nov 27, 2012 @Barnes Jewish @62yrs
    T11 to Sacrum Dural leak at L2 & L3 ccmail4g@gmail.com

  2. #2
    Join Date
    Feb 2012
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    77
    Sorry, but what is BMP?

  3. #3
    Join Date
    May 2010
    Location
    Indianapolis area
    Posts
    970
    BMP=bone morphogenic protein. It's a biotech product used in conjunction with your own bone and cadaver bone to speed fusion. Lenke uses it routinely. His nurse told me sometimes if insurers deny coverage of BMP the hospital will eat the cost of it. But the insurer has to agree to cover the surgery. What was the reason for denying the whole surgery if BMP is used? I wouldn't lose hope yet. They're pretty good at getting insurers turned around over there.

    Evelyn
    age 48
    80* thoracolumbar; 40* thoracic
    Reduced to ~16* thoracolumbar; ~0* thoracic
    Surgery 3/14/12 with Dr. Lenke in St. Louis, T4 to S1 with pelvic fixation
    Broken rods 12/1/19; scheduled for revision fusion L1-L3-4 with Dr. Lenke 2/4/2020
    Not "confused" anymore, but don't know how to change my username.

  4. #4
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    May 2012
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    El Centro, CA & Baja California, Mexico
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    193

    united Health Care

    I was told by the nurse that the 25pg just arrived. I hope that they are reading and re-reading it. She asked me not to call my insurance as not to raise a red flag and that the hospital will help but only if I don't have insurance.

    What is funny about this is that the insurance clearly says if BMP is used then nothing involving the surgery will be covered. The office has not done a pre-authorization for me yet as they need to understand how this would affect the surgery.

    I thought I could pay out of pocket thinking that it would be a couple of thousands but not at $100k. At least is not like I have a fatal illness - nothing that Vicoden can't help at this stage. It seems like the world just crashed but I am better now. I am still healthy and walking. I can look great after a shower, lipstick, a nice dress etc. knowing that I can still function well.

    I am sure that Dr Lenke will have the same document. Dr Bridwell has been using this BMP for over 7 years (I think)

    REad this:
    http://beckersorthopedicandspine.com...geon-responses
    Gardenia
    Baja California, Mexico & El Centro, Ca
    pre-surgery 75 and 89 - post ?
    Dr. Bridwell Nov 27, 2012 @Barnes Jewish @62yrs
    T11 to Sacrum Dural leak at L2 & L3 ccmail4g@gmail.com

  5. #5
    Join Date
    Apr 2010
    Location
    Waterloo, IL
    Posts
    1,707
    Healthlink denied coverage for BMP, but Dr. Lenke assured me that Barnes would absorb the cost, which they did. Healthlink was fantastic with all other coverage and I only paid $250 out of pocket. I hope you can get this issue resolved.
    Karen

    Surgery-Jan. 5, 2011-Dr. Lenke
    Fusion T-4-sacrum-2 cages/5 osteotomies
    70 degree thoracolumbar corrected to 25
    Rib Hump-GONE!
    Age-60 at the time of surgery
    Now 66
    Avid Golfer & Tap Dancer
    Retired Kdgn. Teacher

    See photobucket link for:
    Video of my 1st Day of Golf Post-Op-3/02/12-Bradenton, FL
    Before and After Picture of back 1/7/11
    tap dancing picture at 10 mos. post op 11/11/11-I'm the one on the right.
    http://s1119.photobucket.com/albums/k630/pottoff2/

  6. #6
    Join Date
    Sep 2003
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    Northern California
    Posts
    7,123
    There was a similar problem about 3-6 months ago, with another insurance company. The insurance company eventually backed down and reversed the policy. Hope that happens with UHC as well.

    --Linda
    Never argue with an idiot. They always drag you down to their level, and then they beat you with experience. --Twain
    ---------------------------------------------------------------------------------------------------------------------------------------------------
    Surgery 2/10/93 A/P fusion T4-L3
    Surgery 1/20/11 A/P fusion L2-sacrum w/pelvic fixation

  7. #7
    Join Date
    Jan 2012
    Location
    Yacolt, WA
    Posts
    1,592
    I believe the same thing happened to Doreen....see her blog about her surgery. Like Linda said, they eventually approved the procedure and the hospital ate the cost of the substance.
    Susan
    Adult Onset Degenerative Scoliosis @65, 25* T & 36* L w/ 11.2 cm coronal balance; T kyphosis 90*; Severe disc degen T & L stenosis

    2013: T3- S1 Fusion w/ ALIF L4-S1/XLIF L2-4, PSF T4-S1 2 surgeries
    2014: Hernia @ ALIF repaired; Emergency screw removal Spinal Cord Injury T4,5 sec to PJK
    2015: Revision Broken Bil T & L rods and no fusion: 2 revision surgeries; hardware P. Acnes infection
    2016: Ant/Lat Lumbar diskectomy w/ 4 cages + BMP + harvested bone
    2018: Removal L4,5 screw

  8. #8
    Join Date
    Jul 2011
    Posts
    535

    Same Issue, Same Ins. Co.

    Hi Gardenia,

    I had the same exact issue with the same exact insurance company and this "hiccup" occurred hours before we were given the green light for my central line procedure. Here is what Dr. Lenke had to do, start reading at this page http://thebionicachronicles.blogspot...s-however.html

    It will work out, have Bridwell's nurse talk with Kelly at Lenke's office.

    Warmly,
    Doreen
    44 years old at time of surgery, Atlanta GA

    Pre-Surgery Thorasic: 70 degrees, Pre-Surgery Lumbar: 68 degrees, lost 4 inches of height in 2011
    Post-Surgery curves ~10 degrees, regained 4 inches of height

    Posterior T3-sacrum & TLIF surgeries on Nov 28, 2011 with Dr. Lenke, St. Louis
    2 rods, 33 screws, 2 cages, 2 connectors, living a new life I never dreamed of!

    http://thebionicachronicles.blogspot.com/

  9. #9
    Join Date
    May 2012
    Location
    El Centro, CA & Baja California, Mexico
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    193
    Doreen,
    Thanks for the post. I am so useless in this blog because I am not sure if I place a title it that will start a new thread or not.

    I read what happened to you and I have been reading your blogs and love our exercise and getting out of bed videos.

    However, I could not find where you talk about how it was resolved with the insurance. I know that Drs and their nurses are in constant communication. So, I am sure that this is a new document written in a different way all to make patients more frustrated.

    I am hoping that they can circumvent this roadblock because Bernie said she had to fight the insurance 7 years ago and need to get up to speed as to how the new procedures are. If one insurance does this then others will follow. Dr Bridwell will not use something used a decade before. How is he going to publish the next paper saying that because of insurance lack of 'brains' that he now knowingly will perform a surgery which he believes is inferior without the use of BMP.

    Just guessing and having faith that the group at CAM/Barnes-Jewish will not take this laying down. Bernie said that this is not final and that they are going to be working in a prompt resolution (of course if it will affect a lot of their patients..)

    gardenia
    Gardenia
    Baja California, Mexico & El Centro, Ca
    pre-surgery 75 and 89 - post ?
    Dr. Bridwell Nov 27, 2012 @Barnes Jewish @62yrs
    T11 to Sacrum Dural leak at L2 & L3 ccmail4g@gmail.com

  10. #10
    Join Date
    Apr 2012
    Location
    Harrisburg, Pa.
    Posts
    85

    Bmp

    Hi Gardenia....Just read your post and wanted you to know I will be praying this is resolved. I now have an Aug 27 surgical consult. Gosh, now I am concerned about Aetna Medicare....fingers crossed.
    Patty

  11. #11
    Join Date
    May 2009
    Posts
    3,729
    gardenia, when you read Doreen's blog, go to the
    title list on right side of page...look at the two above the one
    titled "Settled in St Louis"....inlcuding the one titled "Green Light"...
    that will explain what happened....apparently, they can maybe get
    away with not paying for the BMP, as mentioned elsewhere by
    other patients....but then they end up covering all the rest of the surgery, and patient pays for BMP themselves, or the hospital absorbs
    the cost of the BMP....
    probably best ones to deal with these insurance folks are the
    surgeon's staff, who probably have to deal with them all the time...
    plus, surgeon's staff are not so emotionally invested as the
    patient is...

    good luck...sounds like it has been worked out before, so it
    should be do-a-ble again....

    jess...& Sparky

  12. #12
    Join Date
    May 2012
    Location
    El Centro, CA & Baja California, Mexico
    Posts
    193

    thanks Jess

    I followed your instrucition mainly looking at the name of the blog and found everything to read.

    I am hopeful but in the past, the insurance would not cover BMP only. Now, it is not covering anything with BMP. I have been reading articles, of course researching, that BMP has possible side effects eg cancer. That would not be great...
    Gardenia
    Baja California, Mexico & El Centro, Ca
    pre-surgery 75 and 89 - post ?
    Dr. Bridwell Nov 27, 2012 @Barnes Jewish @62yrs
    T11 to Sacrum Dural leak at L2 & L3 ccmail4g@gmail.com

  13. #13
    Join Date
    Jul 2011
    Posts
    535
    My blog states:

    "The Plot Thickens
    Met with Dr. Lenke this morning who is shocked that our insurance is not cooperating. In fact, he said he has never experienced this before. It seems the explanation of denial was lost in several translations, but now boils down to this. Dr. Lenke always uses a product called BMP (bone morphogenetic protein) because it provides a faster, stronger fusion for his patients. Dr. Lenke forewarned me back in September when we met that most insurance companies deny the BMP portion of the surgery. Washington University absorbs the BMP cost. My insurance has decided to deny the entire surgery because of the BMP; so they are not just denying the BMP portion but everything.

    What makes things more challenging for me is that we must have some sort of "surgery only" approval from the insurance company today before close of business because of the holiday tomorrow and Lenke's office being closed on Friday. The clock is literally ticking in the final countdown. Jeremy has escalated as far as he can on our end and now we are waiting for Dr. Lenke to have the peer-to-peer chat with the insurance company directly."


    It was Lenke's peer-to-peer chat with United Health that reversed their decision. Glad the videos are helpful. Keep us posted on the outcome of your insurance.

    Warmly,
    Doreen
    44 years old at time of surgery, Atlanta GA

    Pre-Surgery Thorasic: 70 degrees, Pre-Surgery Lumbar: 68 degrees, lost 4 inches of height in 2011
    Post-Surgery curves ~10 degrees, regained 4 inches of height

    Posterior T3-sacrum & TLIF surgeries on Nov 28, 2011 with Dr. Lenke, St. Louis
    2 rods, 33 screws, 2 cages, 2 connectors, living a new life I never dreamed of!

    http://thebionicachronicles.blogspot.com/

  14. #14
    Join Date
    May 2009
    Posts
    3,729
    Gardenia, i would call AARP on Monday...
    if, as i suspect, AARP recommends UHC for their members, then
    they should be interested in what that insurance company
    is putting spinal patients thru when surgery is needed....
    i would call and try to speak to whomever at AARP is in charge of that
    department....

    jess

  15. #15
    Join Date
    May 2012
    Location
    El Centro, CA & Baja California, Mexico
    Posts
    193

    Doreen1

    As I read your post regarding pre-0p approval, I got confused a bit. I have the date that you joined the forum and the date you posted in response to my thread.. Your signature says surgery Nov 2011.

    I wonder if a peer to peer chat would do the job. Sure that Bridwell and Lenke are in the pool so it would be silly for me to call Bernie and tell her (?) as this is 9 months old and United HCare had time to be more detailed on this document? I am making myself wait as I believe that the office does not want to submit a pre-op approval until later and closer to the date of surgery otherwise the insurance would come back for some other ways to deny.
    Gardenia
    Baja California, Mexico & El Centro, Ca
    pre-surgery 75 and 89 - post ?
    Dr. Bridwell Nov 27, 2012 @Barnes Jewish @62yrs
    T11 to Sacrum Dural leak at L2 & L3 ccmail4g@gmail.com

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