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View Full Version : Anyone get 2 level cervical ADR approved in US? Anyone have PHCS for insurance?


mgs32
11-22-2007, 10:51 AM
Happy Thanksgiving All!

I was in to see my doctor yesterday, and he told me he just found out that as of the first of the year, he will be able to use the ProDisc-C for two levels off trial. I was thrilled, but he warned me that I will likely face a lot of trouble from insurance.

So, I'm wondering if anyone has had a 2 level cervical ADR approved by insurance in the US. If so, how difficult was it, and do you have any suggestions/tips? Does anyone have an approval letter available?

Also, does anyone have PHCS (Private Healthcare Systems) for an insurance provider? I've never had any trouble with them, but have also never faced a major surgery.

Thanks for any advice/guidance anyone has!!

LBP
11-22-2007, 11:28 AM
well I had a 2 level lumbar denied by Pacificare, which was part of the PHCS network. After that, PacifiCare was bought by UHC and I was still denied a hybrid fusion/ADR.

I was told PHCS is just a network of drs and does not make actual coverage decisions. PHCS was a logo on my Pacificare health insurance card. So I'm wondering...don't you have a health ins name offering you a plan that just belongs to the PHCS network?

It was confusing because when I lived in CA everyone knew Pacificare, but when I moved to WI, no one heard of PacifiCare but when I mentioned "PHCS" they said "oh yeah we accept that" But PHCS wasn't the actual insurance company.

Maybe PHCS offers some special plan in Boston but I just wanted to clarify my experience compared to your question.

mgs32
11-22-2007, 12:33 PM
Hi LBP,

Thanks for the response. I think you're right, PHCS is just the network. I guess Trustmark Insurance is my actual insurance provider. I have both company names on my insurance card. To make things even more confusing, I've been told that since I work for a private company, the insurance company is more of an administrator than actually the decision maker. Geez, insurance is so confusing. Anyways, thanks for the help.

LBP
11-22-2007, 05:21 PM
it almost sounds like you're saying your employer is self insured and they use a third party administrator.

If that's true, you'll want to figure out who makes that decision at your company and start preparing to make your case. Some people have been successful getting coverage BECAUSE their company was self insured and they had certain things going for them as an employee like:

how high up in the company you are, how long you've worked for the company, the kind of work (how valuable and indispensible) you are for your company.

Also if you make the dollars case for them...compare prices, possible furture surgeries with fusion compared to ADR etc as well as pointing out how much quicker the recovery is supposed to be for ADR, and thus returning to work sooner than if you had fusion.
You'll probably want to do some research for specific data and articles to prepare for this kind of discussion. You'll want to present a clear and convincing argument for ADR.

You can seach people here for there success with self insurance situations. I know one who doesn't post anymore is ESL but there's someone recent who I cant recall their name.

CindyLou
11-24-2007, 09:08 AM
I do agree with LBP's suggestions all the way, however, on a sour note, it can still play against you. Case in point: my husband's company is self-insured; he has been with the company for over 17 years; he is the highest level executive at the company, minus the owner and one other. The head of HR and the owner made the final decision, and concluded he is already a "highly compensated executive." Translate.....pay for it yourselves. I even had a one on one personal interview with the head of HR, but she had already made up her mind before the appt., as she handed me the "denial" on letterhead while we sat there. I still wonder why she agreed to the interview. Possibly so she could appease her conscience, handing it to me in person. In any event, it's all about the money. And employers and insurance companies will deny till the cows come home, as long as they can still get by on "experimental" and "for one level only." I will never understand that perverted power, if the FDA has approved something, how they can still deny. It's a crazy, mixed up world with health insurance. http://adrsupport.org/groupee_common/emoticons/icon_frown.gif On a better note, "Terry" got his four level covered, I believe, largely due to his status at his company, also self-insured. So, go figure. http://adrsupport.org/groupee_common/emoticons/icon_confused.gif

mgs32
11-24-2007, 12:33 PM
CindyLou & ESR,

Thanks so much for the responses. Unfortunately, I'm only 24 and have been with my company for under 2 years, so I don't think I'll have much going for me in that regard. I'm hoping if it does end up being their decision that I can somehow prove that ADR would end up being less costly in the long run. I'm figuring that with ACDF I would be likely to: (1) be out of work longer (they pay disability for more time), (2) require more PT, (3) be on medication longer, (4) require more surgery in 5 or 10 years. I wish I could somehow find out the exact cost comparison. Any idea how I could do that? If I contact the secretary at the Dr.'s office, is this something she could provide?

Thanks again for all the help.
~ Marissa