New Trick Approve Surgery - Refuse Bill

[kmperry]

I've been reading this forum since I found I needed a 1-level L5-S1 ADR last December. Interestingly enough, United Healthcare approved my surgery immediately. So I read almost all the posts in this forum, scheduled surgery for 4/10/08, put my life in order and was to go in on Thursday. Several days ago the surgeon's office called to say that all the claims for UHC pre-approved surgeries for ADR were being denied because the device was "experimental". Since all claims were being denied the hospital and surgeon would not go ahead with my surgery. I have no rights of appeal because my surgery hasn't taken place yet. I've contacted the NYS attorney general, DOL (ERISA) and today I am sending certified, return receipt leters to the CEO and SR VPs at United. My surgeon is Dr. Federico Girardi at the Hospital for Special Surgery in NYC.

Is there anyone out there who has gotten United Healtcare to pay for 1-level ADR willing to share their approval letters?

I am completely devastated, especially since my daughter is having twins in September and I won't be able to help without the surgery.

Please feel free to PM me at kperr692@embarqmail.com if you like.

[ZorroSF]

I highly advise you to see three surgeons before scheduling your surgery. It's becoming more common place not to give ADRs at L5-S1 due to lack of movement at that level. L5S1 is primarily a shock absorber. After the op you are increasing the range of motion at that level to a point where there will be significant facet degeneration and a higher risk of revision surgery to turn that ADR into a fusion.

It's not fun to go through.

I also noticed your sig and it states bone on bone. You're not eligible for ADR if it really is self-fusing pre-op.

[kmperry]

The L5-S1 hasn't fused yet and in fact moves around quite a bit. I feel the grinding all the time. I had a choice between fusion and ADR and chose ADR because mechanically it makes more sense. I'm a competitive skier and race car driver. The fusion is similar to a fixed suspension and ADR is similar to coil-over shocks. Fixed suspensions went out of use in the mid 1800's and a good set of shocks means the difference between winning races safely and crashing out.

[ZorroSF]

Like I said what we the client thinks and what the statistics state tend to be quite different. ADR at L5S1 is not to be assumed or taken lightly. There is no shock absorbtion with ADR, unless the manufacturer strictly advertised it as such. Hence you will not see any such advertisement. ADR is strictly to increase mobility. At L5S1 you have the greatest risk of facet degeneration.

Off the record you need to be analyzed by an excellent Physical Therapist to determine how your muscles have been compensating since the injury occurred. You also want to find a PT who has had experience rehabbing people after ADR as opposed to fusion.

Your x-rays will reveal if you have adult onset scoliosis (typically brought on by not seeing a spine surgeon soon enough after the injury occurred, and by protrusions rubbing against the nerve root). An MRI can also reveal muscle density of the erector spinae. Any differences between the left side opposed to the right side will also elude to muscle imbalance.

Those are instant ways to determine whether you should receive ADR at that level.

Don't follow the same path of thought I had prior to ADR thinking that fusion at L5S1 is horrible and destined to bring on adjacent issues. IF you're ever going to have a fusion L5S1 is the best spot in your spine to have it done.

[kimmers]

Kmperry,

I like your race car analogy. Following this line, I wonder if I have a Ferrari chassis or a V-W? Just kidding.

If a member on here warns you about a potential problem, I would heed it.
First the insurance problem, Wisconsinguy on here and on the website, spine-health.com, got United Health Care to pay for his double Charite.
If the insurance is denying your treatment, you should be able to appeal once you are sure they are denying it. I don't think it matters that they "approved" it at first, they are denying it. And what about the NY attorney (?) going after the insurance companies, Cuomo?

Secondly, is ADR the correct surgery for you? That is something you are going to have to find out with the help of your surgeon. It is true at L5/S1 there is less worry about preserving mobility. I have read a little bit about L5/S1 ADR people potentially having problems. I didn't do much research on that.
You will have to delve into that, but at the same time you can pursue your insurance to pay for your surgery.
I can tell you before I went into surgery, my surgeon came to me and told me I could end up with fusion if my disc was too deteriorated. It depended upon what they found after they opened me up. I wasn't surprised when I signed the consent for ADR or fusion, because I knew that might be a possibility. I just prayed that I would get ADR.
I had delayed treatment as I sparred with my insurance company, Blue Cross, and I was getting progressively worse and losing disc height.
So be careful.

Good luck with your decision.

Kimmers