Beaten By The Insurance Company.....Again

[Nairek]

Well, I have been beaten my insurance company yet again. Looks like I will be forced into getting a fusion at L5/S1 after all.

We had hoped that my husband's insurance company might pay for ADR surgery since it was self-funded through an international company. Unfortunately the jerks said "No, it's investigational". I caught the nurse off guard when I asked her how they could say that when it's been FDA approved since August 2004. Then I got the usual BS.:flaming:

My OS even took the time out to speak to the medical manager of the insurance company & they still said no. I just about lost it at work when he called me to tell me the crappy news.

Ugh! I give up. They win. I can't keep going on like this. As each day passes I am in more pain. I'm now at the point where I can't sleep on my back because I wake up with pins & needles down both of my legs.

The only other thing I can think to do is try to reach someone at the corporation medical department & see if they can try & help. But with surgery only 6 days away, I don't think I have much of an option & I hear that they aren't very fast when it comes to deadlines.:(

I've been told that a fusion at L5/S1 isn't that bad since there isn't much motion at that level anyway. Are there any L5/S1 fusion folks out there who can confirm this?

[CindyLou]

Hi Nairek,

Sorry about the insurance news. I had my L6-S1 fused last July and don't think I feel less flexible. I have my 3 lumbar adr's above it. I have pain issues but I believe they are hip related. Not fusion related. I'm sure there is some movement at that last lumbar segment, but if you have to have fusion at any level at all, that would be the level, imho. Hope this helps. Best to you with your surgery. Feel free to ask me any questions after your surgery, since I have had both.

[Nairek]

CindyLou,

Thanks for the shoulder to cry on. I'm just so angry & upset about the whole situation. I feel like a fool for thinking that his insurance would possibly pay for the ADR surgery.

Wow! 3 ADR's & a fusion. I can't even imagine going through so much surgery...

I really wanted to have an ADR instead of the fusion but I can't fathom spending possibly $82K (worst case scenario) out of pocket. I mean who realistically could afford to pay for that out of pocket?!?

I'm nervous about the fusion as I have heard not so many great things about it. I spoke with my husband about the fusion route quite a bit. He reminded me that the OS said that I have run out of options. That I need surgery & shouldn't fixate on ADR since fusion will have the same outcome just without movement at that level.

At this point, we have both decided that if I am to have any kind of quality of life, then I should move forward with fusion.

Thank you for offering advice for after my surgery. I'm sure I'll have many questions. I'll try to keep everyone updated as much as possible.

[Toebin]

Nairek,

I too am sorry to hear about the insurance denial. I know you were really wanting to go that route.

If it helps at all, I've had cervial fusion at 2 levels and I haven't noticed any lack of motion in my neck at all. As a matter of fact things seem to move better now for some reason.

Best of luck with the surgery and please feel free to ask any questions you might have !

[Nairek]

Toebin,

Thank you for your reply. I haven't replied to posts as much as I wanted to since sitting is a bit of an issue for me lately.

It's interesting that you have more motion at your fused levels in your neck. I have never heard of that before. Usually it's the other way around ; )

Now, the fun part, trying to stay calm for surgery. It all still seems surreal to me.

[CindyLou]

Nairek,

We'll be thinking and praying for you on your big day. I hope you will be satisfied with the outcome. Most importantly, I hope you get the desired pain relief you deserve. I know how disappointing it is to lose your insurance battle, as many do here on the boards. It just isn't right. I went through my 3 appeals and an in person interview with my husband's HR president. I talked and worked feverishly with The Insurance Warrior author. Who, by the way, was a huge help, even though I lost my battle. It's just such a major disappointment when you feel like you have written and presented a thesis on your appeal. My husband's company is privately insured so I had especially high hopes. Add to that he has been with the company for 19 years and one of their top executives, I even thought that might help. I recall the HR lady comparing me to her 80 + mother who had had fusion and was doing great. She also indicated my husband was already highly compensated, to which I could only conclude was reverse discrimination. You can afford to pay, so pay! At the end of the day, out of compassion, the company finally did offer to pay half our expenses in the form of a payroll check, which was subject to all the withholding taxes, so it ended up being about 1/3 the amount. But, as they say, it was better than a poke in the eye. And they also paid for a roundtrip first class ticket for me which I was very thankful for, especially flying home from Germany with 3 new lumbar discs in me. The crazy thing was, flying home, I had the ONLY seat in first class that was broken. It wouldn't recline at all. I freaked out, to say the least. After discussing my situation with the airline staff, they made an announcement in first class, offering anyone who was willing to give up their sit for me another set of roundtrip first class tickets, and fortunately, 1 person, a woman about my age, raised her hand and said she would take the broken seat. I was beyond thankful. I like to think the amount of compensation I did receive was totally linked to how hard I worked to present my case. If I hadn't appealed, I likely would have received nothing.
We'll be here when you get to the other side!

[Toebin]

Nairek,

The important thing is to consentrate on the positive and think of how much better your pain situation will be after they fix your issues.. I think in my case my neck was so messed up that getting all the bone spurs removed and all the bad disks taken out that it made everything else move around better. Can't say for sure, but I too was hoping for an ADR, wound up with a fusion and it's worked out..

I've always had a very strong sense that despite everything you do and plan, things happen for a reason.. sometimes we don't know what that reason is, but ... well...we'll know eventually.

YOU take care and we'll be here waiting for you when you get to the other side.

[Sandra L]

CindyLou, Thanks for the shoulder to cry on. I'm just so angry & upset about the whole situation. I feel like a fool for thinking that his insurance would possibly pay for the ADR surgery.

Wow! 3 ADR's & a fusion. I can't even imagine going through so much surgery...

Nairek,

I can't respond from first hand knowledge, but I've read that a lot of people go fusion with S/1 and are able to have ADR later if necessary, like CindyLou. (CL the audacity of some people, highly compensated, pay for it :raspberry::raspberry::raspberry: - you should have reported her)

I think for your own peace of mind and so you will be in the best condition for your surgery, you need to put the :flaming: behind you. Be positive. I really believe that this will be best way for you.

You will be in my thoughts and prayers during your surgery and after. Sandy

[kimmers]

Good luck with your surgery.

As far as I understand self-insured companies, this means the company itself pays for the surgery. So if anyone's husband or wife works for that company, they need to go to their boss and the top hancho to get approved.
There are people who used this approach and got approved.

My husband once worked for a self-insured company and we had a premature birth. So his company tried to stick us with the bill, saying we were not insured.
Fortunately, that did not hold water, especially when we got an attorney to intervene.
Might not help you now but be careful of self-insured companies. As I understand it, only big companies should be self-insured as they can spread the cost.

Kimmers