Aetna updating their CPB on ADR 7/10/14
 

Aetna is scheduled to update their clinical policy bulletin on ADR today, July 10, 2014. The last update was March 2014. Before that, 2012...2009...


Here's the link.

Intervertebral Disc Prostheses

I have Aetna and looking to get ADR. Any word yet on the ruling? I did a search and only found that it is still the old ruling.

Thanks,
Rob

No update yet
 

Aetna hasn't updated the CPB yet. Apparently they go through the CPB list routinely and assign a group of bulletins a date to be reviewed, so the "next review" date is the beginning date of the reviews for the whole group. I'm not sure how long they take.

I check the CPB daily and as soon as it changes I will post here. :D

Here is the current one, with review date 7/10/14

Intervertebral Disc Prostheses

Rob, you need a lumbar replacement? Your signature doesn't specify

yes...i have been told that I am a great candidate for one.

So if Aetna isn't covering ANY lumber ADR's, who IS in the US?

Good question Hanshan. I haven't looked up the other insurance policies because it doesn't pertain to me. Maybe others will read this post and offer their policy info.

I do know that Aetna, to date, has not changed their clinical policy bulletin yet. I also know that there are two companies who are allowing two level CERVICAL ADR as a standard, which are United Healthcare and Cigna.

Are you able to switch insurance to a company that will allow a 1 level lumbar? If so, is there a clause that disqualifies you for a pre-existing condition? Worth investigating if this is the case for you.

I expect things will only get tougher and tougher for us as time goes on, beginning with the turn of the new year. Healthcare is on the decline, as my opinion is educated (I work in the healthcare field) and honest (I am a glass half full type of person but reality is what it is) :D

Can you expand on your reasoning? ADR is so well established in Europe that I don't see how insurance companies can justify denying this stuff. I am hoping that Activ-L will be accepted by the FDA soon and covered by somebody out there. If not, I might go with BCBS and try to see Dr. Clavel for the M6.

Hanshan, only time can be the true teller of how our healthcare will look, but unfortunately healthcare in the US isn't driven by care as much as it is financial gain. It doesn't always come down to what is best for people, but what is most profitable for big insurance companies. Consumers can push and persuade the industry to a certain degree, but now the government has stepped in with obamacare, so I project that we will have less and less choices at a higher cost, regardless of what is best for a patient. You already see this in the form of denied claims due to "not medically necessary" "experimental/investigational" and such. Do these statements hold true to the claims they are denying? Of course not. Then how can they get away with this, you ask? Good question. But they do, and it isn't going to get better. That's my opinion, for what it's worth.

I don't understand why they claim ADR is more money when in all actuality ADR is cheaper. Less time in the hospital 23 hours vs 4 days or so. Also, it is no longer experimental -- just show your insurer during your denial that it has been used on patients in the U.S. since 2004-2005 and it is much safer, cheaper and that in than in the future those fusion patients will be returning back most likely for another fusion. There are articles out there in the internet - use them for your appeal.

I don't understand why they claim ADR is more money when in all actuality ADR is cheaper. Less time in the hospital 23 hours vs 4 days or so. Also, it is no longer experimental -- just show your insurer during your denial that it has been used on patients in the U.S. since 2004-2005 and it is much safer, cheaper and that in than in the future those fusion patients will be returning back most likely for another fusion. There are articles out there in the internet - use them for your appeal.

Colorado babe, it does not make sense does it...that's my point. I personally, over 8 months and 4 debates, have lost my appeal fight. There are no other options for me, unless I pay an attorney which would cost me thousands. I don't know how they can approve the surgery for some, and not others, but they do. I don't want to count your advice as useless, but I do feel you have been blessed with one of the few "lottery tickets" to be granted surgery (paid for) while some of us who are just as deserving are not afforded the same gift, and you assume it came down to your appeal...It's easy for you to say "add this or that in your appeal" as if that has anything to do with the outcome. Reason and logic has no place in this game but chance and circumstance prevail. If you were to read my 82 page final appeal, you would see I left no detail unaddressed and no room for question the logical and ethical reasons for why my surgery shouldn't be allowed. Fair? NO. Reality? YES.

Hi Kelly,
I just posted in another thread some of the appeal variables that may come into play when looking at outcomes. These include insurance carrier, type of procedure, number of disc levels addressed, support by local docs, and many more. However, I also agree with you that there is some randomness as there are different reps within the insurance carrier reviewing the appeals, different moods they are in, etc.

Bottom line in my opinion is that it is worth it to try to obtain approval or be reimbursed for the surgery. It is also important to manage one's expectations so that you are not terribly disappointed if you are ultimately denied.

Incidentally, Cigna does not accept 2-level cervical ADR as there guidelines have many exceptions. I suspect that it can be random as well.

I did have my congressman involved and maybe that was the reason, I don't know. It sure doesn't make sense to me but if anyone wants to use my reversal for their case, pm me and I would be happy to supply it for you. I am with Tricare but I used the Cigna case and it was very helpful.

Aetna has updated their CPB
 

It appears that Aetna has "updated" their clinical policy bulletin 11/12/14. It also appears that nothing has changed.

Intervertebral Disc Prostheses

Insurance
 

Hello Kelly,
I will switch to Aetna, only because it is HDHP and I can get a HSA, but insurance in the USA, since the Communist (My Opinion) (Death Panel) ACA was put in place, won't matter in a year or two (if not REPEALED 100%) anyway.
.
All we will have is a Bureau of Motor Vehicle, stand in line type care anyway.
.
To compare the ACA to the VA, is Non-Sensical, if this is implemented, it will be NOTHING like the VA.
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BCBS(Blue Communist Blue Socialist) care is about as bad as paying a toll and not using it, I pay A LOT of money, and receive about 40%.
They are denying the Surgeons fees for BOTH of my surgeries.
.
This is just ridiculous, if they could only live like that for a few weeks, they would change their tune.