Need insurance/doctor help.

[Moadr]

I have been approved by Pacificare for lumbar surgery and cervical fusion. But have been turned down for cervical ADR. I have to have the cervical done before the lumbar as my spine is being pinched by 40%. I have access to the top surgeons for Prodisc and Prestige - Dr. Delamarter and Dr. Pashman. And can change to any insurance. Aetna covers both.

I'm leaning towards the Prodisc. But neither doctor are "in network" for any insurance that covers ADR. So my first question is how can I find out which doctors that have performed the most of these types of procedures - that are "in network"?

Secondly, which has the longest track record in the US and/or overseas - Prodisc or Prestige? I'm leaning towards Prodisc for it's ease of installation, ability to place more in later above and below, the untested slight ability to some day be able to replace the plastic piece if it wears out (where as with the Prestige if it wears out you have to have it removed and fused), and if Medtronic thought the prestige was superior design they would not have built the Bryan(sp?).

Dr. Delamarters office has been very fair about telling me about both devices. I was told both are very good. Which I respected. But I still think the Prodisc appears mechanically to be better placed and a simpler design.

Any help would be greatly appreciated.

Patrick

[LBP]

well Patrick, I just had 2 level Prodisc L4-5 and L5-S1 with Dr. Westerlund in Encinitas CA, just 2 hours ish south of Dr. Delamarter.

Dr. Westerlund was in one of the investigators along with Dr. Delamarter in the ProDisc trials.

I orig met Dr. Westerlund because he accepted Pacificare but I too was denied ADR surgery. So when I finally got Aetna Medicare insurance I went back to Dr. Westerlund and was approved. I am 3 weeks post surgery.

I will say that I didn't love my treatment from most of the RN's at Encinitas hosp but I did like my spine surgeon Dr. Westerlund and Dr. Dandan (the vascular surgeon). Another ADR surgeon in this office is Dr. Peppers.

They are at core orthopaedics, Encinitas CA

Good luck.

[Moadr]

I wonder what differences there are between Lumbar and Cervical ADR as it pertains to our conversation here. You had lumbar. I need cervical.

How much did Aetna pay? Which plan are you on? Was it a long process or did they just approve you right away?

I have to make a choice by next thursday the 1st or I have to wait another month.

Any idea if your doc does cervical too?

Thanks so much for the info! Really helps.

P.

[Terry]

Patrick:

The Bryan Disc was made before the Prestige. The Prestige is a newer disc. I believe the Pro-disc and Prestige disc both have their applications and patients that they are appropriate for.

Terry Newton

[LBP]

here's the link to Core's website:

http://www.coreorthopaedic.com/twt~page~itemid.37/Spine.html (http://www.coreorthopaedic.com/twt%7Epage%7Eitemid.37/Spine.html)

I believe that they do cervical but I don't keep up with what is FDA approved in that area vs what is in clinical trials.

I would suggest calling them.


As far as what Aetna ins plan I am on... It's Aetna's Medicare Open Premier Plan. I was eligible for this plan because I won my social Security disability appeal and selected a comprehensive Medicare plan via a private insurance company. Again, as a PFFS (opposed to a PPO, HMO etc,) I didn't have a specific limited network. I could go anywhere that accepted Medicare and who was willing to accept my insurance. Private Fee for Service (PFFS) is a new Medicare Ins product this year.

I was approved within a month of seeking pre auth. No appeals etc. I picked a plan where almost everying is coveed 100% with 1K hosp coppay. As far as what Aetna paid to the hosp and drs for the surgery, I don't know yet. I am not home so I haven't opened any mail for a month. I don't believe they have even sent any Explanation of Benefits for my surgery yet.

It seems like almost everyone with Aetna gets approved for ADR surgery but I do believe that there are a few people on this website that were denied ADR with Aetna. The more comprehensive a plan the better, and going to drs who where doing the clinical trials may help things to fall in your favor.

You should search here under "find" in various forums for aetna and see if you can find out what plans through employer provider ins that
aetna has and has not covered
ADR.

best wishes

[Harrison]

Thanks LBP, nice post. Hope you are better and stronger every day.

[Moadr]

Thanks for all the information. I will be going thru the list of doctors involved in Prodisc studies and see if any in CA accept Aetna. That is the issue at the moment with Dr. Delamarter. He is not in network with Aetna. So it remains to be seen how much physician fee/detectible/out of pocket max I would have to pay. Hospital and anesthesiologist is covered.

It's an impossible financial equation. No one will say how much they will or won't pay. Very frustrating. Even when trying to just decide which Aetna plan to take.

Thanks again.

Moadr