US/California insurance and ADR by Dr. Bertagnoli in Germany question
 

Hi,

I just got a recommendation from Dr. Bertagnoli of two level ADR into c45 and c56.

Even though two level Mobi-C was approved by FDA last month, US surgeons need many years of experience to do multi-level ADR consistently right.

Can someone give me an idea how to deal with US/California insurance companies in order to make the surgery in Germany less financially unjustified?

I greatly appreciate any advises and help...

Cheers,
Vlad

Vlad,

There are currently some attempts for insurance reimbursement for surgical ADR intervention overseas. A few have been successful. Myself, I had submitted all of my information from my surgery with Dr. Bierstedt (operative reports, financials, etc.) to the global portion of my insurance (BC/BS-Illinois).

Although the Mobi-C has been approved for two-level in the U.S., is this the ADR device that Dr. Bertagnoli suggests for you? In my experience, his preference is usually with Pro-Disc (also approved in the US, but I believe there is a newer model - not sure if that one is approved).

Like most of us, we have had to prepay and hope for some type of reimbursement. You may want to contact your insurance carrier for submission requirements or predetermination of benefits.

This is one area that is still unchartered. The ADR is more reliable and logical than dealing with the insurance bureaucrats.

Vlad,

This link is a thread on this site where the poster got BCBS to cover her two level ADR in Spain. She doesn't post here very often any more, but between her post and PM-ing her, you might get some good information.

Best of luck, Jeff

Laura
Thank you for the response.
I was not told which ADR device Dr. Bertagnoli going to use in my case, I assume it’s “Prodisc-C Nova”, “Prodisc-C”(approved by FDA for single-level) is not designed for multi-level surgery.
What is the irony… I work almost across SpinalKinetics’s headquarter in Sunnyvale,CA but ther M6 ADR is not for the US, not cleared by FDA :-(
Cheers,
Vlad

Hi Jeff,
On doctor Bertagnoli website i see reccomendation to work with "Third Party Administrators (TPAs) to facilitate reimbursement"
Insurance
Did you heard of anyone doing it?
Cheers,
Vlad

Vlad,

The poster that goes by the handle, gymnist1981, had a third party involved in her successful appeal. I never quite understood the process she went through, but here is a link to her explanation. She had a successful ADR surgery and continues to do very well today. She doesn't post here anymore, but if you PM her, she might respond.

Good luck, Jeff

This is what I've done so far.

I've talked with my insurance and company HR insurance administrator. They wanted a pre-auth before they would discuss covering a foreign surgery. When the Mobi-C cleared 2-level approval I found a doctor that could perform that surgery and requested a consult and then pre-auth from him. The procedures have been approved stating that they are medically necessary for me. I hope to discuss this with my HR rep tomorrow.

Just thought i'd update on my insurance pre-auth. I was unable to convince my company to pay for Dr L, a US doctor, performing this surgery abroad. They did say they would pay for the Mobi-C at 2-levels by Dr L (at 60% out of network).

The issue that upset me the most was not if they could justify paying for it but if they could justify not paying for it. Given what i have done for this company it really makes me question if i want to continue to work for it.