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In January my wife had a pallidotomy.  (So far very
successful!)  For a time we had a struggle with the
insurance company.  "Experimental procedure" of course.
Thanks to those on the list who responded to our request
for information.

After some effort, the insurance company did pay their share
of the cost.  What we did may be interesting to others. Also
of course this is just information, we do not recommend it
to anyone.  The company may have made their decision in spite
of what we did.

We had two opportunities for appeal of the "Experimental
Proceedure" decision.  For the first appeal we were
encouraged to state the medical neccesity and benefit of
the surgery, so we told of the pain and difficulties of
of her condition and most importantly,of the imminent
loss of her livelyhood.  The appeal told of how these problems
had been controlled by the surgery so that life was again
tolerable and she could continue with her occupation.

The terse response to this appeal was that pallidotomy is
determined to be experimental and according to the insurance
contract, benefits are denied.

There was one appeal left and this one better be right.
Reading the insurance contract, medical neccesity and benefit
are irrelevant if a procedure is considered experimental.
However "experimental" is defined as being determined only
by published papers or reports in the recognized medical and
scientific literature.  We managed to get a call to the person
responsible for making the decision to ask for citations to
those papers or reports from the recognized medical or scientific
literature that had been used to make the "experimental"
determination.  After "going back to check the records" and a
few more calls, the short answer was that there were no such
publications used.  We were in the process of preparing an
extensive appeal that stated that the company had cited no
publications and giving citations to papers of Dr Laitenen,
among others in the literature that reported the benefits of
pallidotomy, when we received a call from the company saying
that they would pay.




  Erv Schroeder              [log in to unmask]
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