Insurance approval for cervical ADR? Help!

[Jayne]

I'm building my appeal and gathering as much documentation as I can find. I have a lawyer & am waiting for Laurie's book to arrive. I'm pretty desperate for surgery as I'm a breath away from total disability (no pay, disaster for me). Original surgery was scheduled for October 2007 and things have deteriorated since then.
I have been told that if I self-pay for ADR my insurance company will not cover any future neck issues. How have those of you who self-paid handled the risk of future neck problems or complications?

The alternative of fusion now pretty much guarantees at least 2 additional surgeries in a 12-18 months, but my insurance won't consider that aspect.

Has anyone gotten approval from Principal Insurance Company?
Anyone who has had any insurance company approval that was paid on cervical ADR, if you've got a moment please reply with what you had done (level, prior surgeries), insurance co., and date. It can only help my appeal to have specific examples of coverage.

I appreciate any tips or information you can provide!
Jayne.

C5/C6/C7 fusion 9/11/2002;
DDD at C4 and C7, C3 injury with some arthritis.
C3/C4 and C7/T1 now recommended for ADR, C4/C5 also recommended for ADR if I can wait until adjacent level ADR is available.
Dr. tells me fusion on C3/C4 now (most symptomatic) will result in fusion on the two additional levels very likely within 18 months due to status of DDD.
That means C3-T1 all fused at the age of 45-46, extremely undesirable and so much missed work time I may well be laid off.

[Terry]

Dear Jayne:

I had 4-level ADR surgery November 2006. My surgery was covered 100% by my insurance company. I also have no problems with getting additional coverage since I had the surgery. All of my physical therapy has been covered as well as appointments to my Physiatrist, medications, spinal injections, etc. My surgery was done overseas in Germany.

I wish you luck in your hurdles with the insurance company. You deserve to be well.

Terry Newton

[Harrison]

Jayne, thanks for posting. Hey, for what it’s worth – fusion get’s a bad wrap on this forum for all different kinds of reasons, but for some people it is the most appropriate procedure. Can you clarify what you meant by this statement:

The alternative of fusion now pretty much guarantees at least 2 additional surgeries in a 12-18 months, but my insurance won't consider that aspect.

Some percentage of fusion patients may need to get an another fusion down the road because of adjacent level degeneration – but 12-18 months would be very unusual. Then again, it depends on the actual pathologies of the disease(s) affecting the spine.

So, back to your conundrum: will your insurance company cover any possible “issues” relating to a fusion procedure?

Just to give you one other thing to ponder – there are cervical ADR trials involving several different arthroplasty devices throughout the nation. Many folks within this community have received cervical ADRs within FDA trials (me, for instance).

Regardless of that issue, it seems many people here done very well with cervical ADRs, perhaps moreso than lumbar ADRs. Why? That’s another story.

[Jayne]

Harrison,

Thank you for responding. I appreciate any & all thoughts on how to best proceed.

In answer to your comment:

Originally posted by Harrison:

Some percentage of fusion patients may need to get an another fusion down the road because of adjacent level degeneration – but 12-18 months would be very unusual. Then again, it depends on
the actual pathologies of the disease(s) affecting the spine.

Currently C3 is the level causing me substantial disability, I will have to have surgery very soon or go on disability until I do have surgery.
C4 and C7 have deteriorated primarily due to adjacent disk degeneration as I had fusion on C5 & C6 in 2002. My doctor verbally recommended the optimum approach would be ADR on all three levels if I could wait until the Bryan artificial disk becomes available. Since only the Prestige was approved by the FDA, the planned surgery on 10/07 was ADR on C3 & C7. C4 shows deterioration similar to C7 but is causing little or no symptoms at this time. C7 has caused significant symptoms that can be partially controlled by cervical selective nerve root blocks for some indeterminate period of time. My phsycian advises me that if C3 is fused in addition to C5/C6, that C4 level would be lucky to hold out for 6 months given the degeneration already present. C7 "might" hold out longer (12-18 months) provided the nerve root blocks continue to provide partial relief.
After all 3 levels are addressed in the near future, if fusion is the only option then I would have C3--T1 completely fused at 46 years of age. Cervical ADR is the better path for me at this time.

I've been told if I self-pay for ADR, "complications" would not be covered. I'm concerned that the insurance company would label any future problems at other levels as "complications", essentially leaving me uninsured for all neck problems. This is the only thing that has stopped me from already getting ADR on C3 and paying myself, the pain & disability has been so great.

I would seriously consider an ADR trial if one was open that I qualified for, but I'm not aware of any currently.
As a side note, my surgeon was involved in the 2002 clinical trial (which only applied to single-level procedures at the time, so I was ineligible). He is one of the leaders in using cervical ADR and well-known at the forefront of his field. Last time I inquired, there were no open trials I qualified for but I'll research that again.

I'm doing everything I know to do in order to get insurance approval, but if that fails I'm faced with a difficult decision.

What are your thoughts?

Thank you,
Jayne.