ProDisc C Approval from Insurance

[Harrison]

Hi folks, I was just curious if any of you have heard rumblings from insurance companies on the coverage of ProDisc C or Prestige...I've heard a few rumors that BCBS may have changed their policy to cover it -- but not sure if this is state by state or unilateral...here's the FDA approval of the ProDisc C from 13 months ago:

http://www.fda.gov/cdrh/MDA/DOCS/p070001.html

Thx

[kimmers]

Harrison,

Can't sleep so I thought I would check the latest TEC assesments by BCBS. I see the same BS.
I.E. Not enough studies to demonstrate long term effectiveness, non-feriority study was not correct, blah, blah (this was for lumbar and cervical).
I did see that florida's BCBS reviewed and came out with a statement on 1-1-09, denying coverage. Next review is 8/27/09.

I did come across a South Carolina court document, where it looked like someone took BCBS to court there for a Charite ADR (lumbar) under ERISA, I think, and the court ordered BCBS of South Carolina to reverse its ruling because basically they did not adhere to their policy of denying the treatment as experimental and investigational.
This lady won.
It was the South Carolina Administrative Law Court. (the date on the upper right hand corner is 1-28-09) (I wish I had this when I was appealing BC).

You may have to excuse my ramblings as had the epidural today and I am not supposed to make any important decisions. Plus I love it when BC gets it handed to them.

Kimmers

[trucklt]

BCBS isn't budging on ADR any time soon. "Nairek" was just turned down by BCBS of New York last week for a Charite. My surgeon in North Carolina says that he hasn't gotten approval yet for an ADR from BCBS. BCBS of New York did approve a one-level fusion for me with one phone call. Fusion is apparently still considered the only "proven" surgical intervention for advanced DDD.

[kimmers]

Truckit,

BCBS hasn't changed their TEC assessment yet, but they do approve surgeries. I personally know one person who was approved and know some others from this forum.

I really believe the more people really fight them, the better chance of patients getting ADR surgery.
You got to check out the South Carolina court document. Just google, Blue Cross TEC assessment and that is how I found it.

I believe there is hope out there. Looking at the percentage of successful surgeries, I believe ADR has higher percentage than fusion. I know of too many people who have had adjacent disc degeneration with fusion, had there hardware taken out, had nerve damage from misplaced screws, etc...
ADR is not the slam dunk but it is as good or better than fusion and that in my mind is a slam dunk.

As always, I say keep fighting. The old adage, when there is a will there is a way is true.

Kimmers

[jchebert1979]

I have BCBS of Texas (although I live in Louisiana) and this is directly from their site.

Coverage:

Cervical Disc Replacement

Artificial intervertebral cervical discs may be considered medically necessary when ALL of the following criteria are met:

Disc has the approval of the U.S. Food and Drug Administration (FDA); AND
Disc will be used for single-level reconstruction (C3-C7) following discectomy; AND
Patient has intractable radiculopathy and/or myelopathy due to herniated disc or osteophyte formation; AND
Patients has failed at least six weeks of conservative therapy; AND
Symptomatic nerve root and/or spinal cord compression documented by ALL the following:
Neck and/or arm pain; and
Functional and/or neurological deficit; and
Radiographic studies (e.g., Computed Tomography (CT), Magnetic Resonance Imaging (MRI), x-rays, etc.).
Artificial intervertebral cervical discs are considered experimental, investigational and unproven for all other indications, including multi-level use, whether done simultaneously or at different times.

Lumbar Disc Replacement

Artificial intervertebral lumbar discs are considered experimental, investigational and unproven.


This is the link to their policy. It is interesting because it even gives information that with fusion there is an increased risk of degeneration of the adjacent levels. I will be trying to get pre-approval this week. I will definately let the board know how it goes.

http://medicalpolicy.hcsc.net/medicalpolicy/home?corpEntCd=TX1&corpEntCd=IL1&ctype=POLICY&cat=Surgery&path=/templatedata/medpolicies/POLICY/data/SURGERY/SUR712.028_2008-06-15#hlink

[jchebert1979]

sorry, for the above link you have to agree to the terms and then type in "artificial disc" in the search box. The results will show up and click on the link. I copied the direct link, but I guess you have to agree to the terms first.

[Frankg]

Does anyone know if United Healthcare has a policy on cervical adr, prodisc-c or multi-level adr?
Does it difer from state to state with UHC?

[CRob]

FrankG,
Looks like UHC may be covering this now. Not sure about state to state.

https://www.unitedhealthcareonline.com/b2c/cmaIndexResult.do?channelId=016228193392b010VgnVCM 100000c520720a____&htmlFilePath=/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesHtml/MedicalPolicies/Artificial_Total_Disc_Replacement_for_the_Spine.ht m

I was looking at having this done about a year ago and got denied once by UHC. I had been doing much better without surgery and then this past weekend while working on putting air conditioner in my camper started feeling quite a bit of pain. Hopefully it's pretty temporary, but started looking around to find out of artificial disc is being approved by UHC now and ran across the above link.

[billyboy710]

Hi everyone,

My NS and I decided to go ahead with ADR ProDisc L for L5-S1. BC/BS still denied coverage after my surgeon had a peer to peer with their medical representative. What's strange is that they agreed to pay for every cost involved in the surgery except for the actual disc itself. My surgical group originally told me that it cost $10,990 purchased from Synthes but they've since got it down to $2,200 dollars. Luckily, the company I work for has a self-funded insurance program and our CEO can override the decision. I'm waiting for his answer as I have a surgery date of Aug. 12th. Keeping my fingers crossed!!!

[JasonR]

Hi everyone,

My NS and I decided to go ahead with ADR ProDisc L for L5-S1. BC/BS still denied coverage after my surgeon had a peer to peer with their medical representative. What's strange is that they agreed to pay for every cost involved in the surgery except for the actual disc itself. My surgical group originally told me that it cost $10,990 purchased from Synthes but they've since got it down to $2,200 dollars. Luckily, the company I work for has a self-funded insurance program and our CEO can override the decision. I'm waiting for his answer as I have a surgery date of Aug. 12th. Keeping my fingers crossed!!!

My company got involved to get my denials reversed as we are self-insured as well. Make sure you get your HR dept as much info as possible. What really helped me was the reduced recovery time that ADR's usually have over fusion; at least for cervical ADR's.

[Alynn]

Does anyone know if United Healthcare has a policy on cervical adr, prodisc-c or multi-level adr?
Does it difer from state to state with UHC?

Frankg: ( and everyone):

I am currenty in the process of pre-approval for a Total Disc Replacement (C6 - C7) with United Healthcare, using the Prodisc-C Artificial Disc. When (thinking positively!) approval is granted and surgery scheduled, I will post back.

Actually, I will post back whatever the outcome, because my surgeon has already told me we could appeal if it is denied.

I am grateful to this website (and others) for all of the information that is provided. I am very new to this, so I'm learning an awful lot!

Best Always,
Alynn