Navigating insurance & getting authorization to see Chiari specialist

General
1

Hey there fellow Chiarians. I figure many of you have navigated the insurance gauntlet and hopefully might be able to coach me through mine.

I received word last week that Dr. Batzdorf, head of UCLA's Chiari program, has reviewed my MRIs and medical records and has okayed me coming in for an appointment. That's fantastic news! Now...to get insurance on board.

I have Blue Shield's HMO with a point of service option. This means I can treat it like a PPO as long as I stay in network (UCLA is in their provider network, thankfully), but I pay 20% of anything they do (MRIs, surgery, etc.). If, however, I get a referral from within my HMO, everything is essentially free for me. The idea of paying 20% of a surgery is NOT pleasant, but it'd be worth it to have one of the best in the country doing it.

I contacted my PCP and they've written a referral for me to see this doc at UCLA, but she did warn me that it's hard to get referrals there because she's just a "lowly PCP." I may need to go convince the neurologist who completely dismissed my Chiari to write a referral to UCLA as well. Or, the medical group might try and get me to see one of their neurosurgeons in their local network, which I'd really like to avoid as none of them are listed anywhere as being known for treating Chiari.

For those of you who've been there, done that, do you have any insights, suggestions, or ideas? Should I just use my POS option and eat the 20%?

2

I am fighting this battle also for my 11 year old daughter. We have been denied twice already. Look up your state board of insurance for exactly how many appeals you have and the exact time frame they have to be done in.

We actually talked with a lawyer who told us we have to document that any in network NS are not Chiari experts. I just posted looking to see if anyone know how to get the official statistics of how many Chiari surgeries a doctor actually does. I know hospitals have these records. You could use those numbers to show why you should be at the specialists.