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Cynlite 03-08-2015 04:35 PM

Two Level ADR U.S. Pay out of Pocket
 
My original post was moved to the International Assistance Section but, I'm considering all options. In this post, I would like to focus on getting a Mobi-C 2 level disc replacement in the U.S. paying out of pocket.

Since my insurance is most likely going to turn me down and I'll have to appeal for a year without knowing if I'll be successful, I want to investigate the cost of a two level cervical ADR anywhere in the U.S. with a great surgeon. Anyone who has had this done and paid personally for the surgery, I would really appreciate your input on the cost and the surgeon! Thanks so much!

I'm still waiting to see my surgeon at the Barrow Institute later this month but, here's a summary of what's going on with my neck in the January 2015 MRI:
  1. I have narrowing at C3-C4 with a 2.4mm osteophyte;
  2. a broad based bulge at C4-C5;
  3. a 4.5mm osteophyte at C5-C6 and
  4. at C6-C7 there was an auto fusion around 2010 after two foraminotomy surgeries to fix that level several years prior.

P.S. I did grab this information from a post from Kelly4ADR who had her surgery in January 2015:
Dr. Richard Wohns, MD . His clinic name is Neospine and he is in WA.
2 level Mobi-C $35 K

Jerry5 03-08-2015 07:56 PM

Do it
 
Document everything, pain meds, tests, MRI, doctors reports, have the doctor file for you, then do it yourself, if they don't pay, and you decide, then get receipts for everything and appeal, it works, sometimes.

But you will be able to move on with your life.

All the best,

Cynlite 03-08-2015 11:35 PM

document, document, document
 
Documenting everything is a given. I was turned down for Social Security Disability after four consecutive surgeries, acknowledging my fate and filling out all their extensive paperwork and then being instructed to see the Social Security Doctor who asked me to jump up and down! I just barely made it to his office. I refused because although I knew I could do it, it would have caused me a considerable amount of pain and who knows what kind of damage. I have no kind words for our system. The doctor said I was just fine to work. This forced me to hire a lawyer who then informed me that the doctor was hired to say that so they could turn me down and our judges will not award Disability to someone not represented by a lawyer. Of course, I still had to do all the paperwork for the appeal too. The lawyer's job was to show up in court with me by his side, answer 10 minutes of questions and collect his 20% fee. After three years of no income and four surgeries plus an appeal, I got finally got it. Thereafter, I had two more surgeries that still didn't get me back in a state of being able to work. I suspect dealing with the insurance company will be a similar joyless battle. I keep meticulous records!

Right now, my focus is on trying to find a solution to this endless cycle of pain. I'll fight the insurance company if I think it's a fight I can win. I may even hire a lawyer because the system is designed to wear us out and make us go away. This is how a for profit health care system operates.

CGR 03-09-2015 10:29 AM

Cynlite,
The Mobi Cervical is approved in the U.S. for 2 levels, I believe. That FDA approval data might assist you in your documentation.
Thanks,
Carolyn

Cynlite 03-09-2015 11:36 AM

Yes, it is approved for two levels in the U.S. Thanks for your thoughts regarding the FDA approval data. I'll keep that in mind for my insurance appeal.

Jerry5 03-09-2015 08:00 PM

Insurance
 
The Insurance in the USA is bad and it will get A LOT worse, if at ALL.

I am waiting to see how much longer my distraction will take and what if any permanent damage I have.

The Fighting for me lasted over a year, and I finally paid, funny, they did give me some reimbursement, but only after a long battle, much pain, and they would let you die from all the pain meds, rather than let you have a surgery and be done with it.

Let us hope we can get some 'reasonable' politicians in office,

REPEAL this monstrosity,
TORT reform and access for ALL insurance in ALL fifty states.
The state by state insurance is HORRENDOUS, they fight every procedure, and there are 20 bureaucrats for every medical person, and even a lot of these are not Doctors, this is INSANITY.

I wish you all the best, if you can pay for it somehow, that would be best and get reimbursement, if not, schedule the doctors appointment and proceed as far as you can, fight this, there is NO reason to NOT pay this, and you have an FDA approved device.

again, good luck.

colorado babe 03-10-2015 10:43 AM

Fortunately for me, I did get my insurance to pay for a multi-level ADR in the Cervical using the mobi-C. It only took me 3 months to do three appeals but the key is responding back within a week of the denial. If you take the 30-45 days to do the appeal, it will take longer.

The problem I see is people don't want or can't fight and the insurance companies are banking on you giving up. In my appeal, I researched evidence based practices on the www to show that this procedure is not investigational. I also included medical journals that show that fusions are more costly then ADR and that studies show the recovery period is quicker as well. I included the studies as evidence.

I explained in my appeal the reason why I didn't want fusion and that I should have a decision on what is right for my body and how the artificial disc was going to be better for me due to my activities and active lifestyle. In my particular case, my injuries were inflicted when I was on active duty and I emphasized it in my appeal.

Don't give up. There is hope -- we need to fight and show insurance that were not going to take "NO" for an answer anymore.:clap::clap:

Good luck!

Cynlite 03-14-2015 10:30 PM

Colorado Babe, thank you for your thoughts on how to tackle the insurance company. Three months is a long time to wait in pain but, better than waiting a year. I guess I'll cross that bridge when I get there next week after seeing the surgeon. I've seen a lot of the data you mentioned on the web. Obviously, the insurance companies have seen it too by now! The corpocracy in this country just makes our country look bad in this world and Americans suffer because of it. Perhaps being active duty and having Tri-Care (assuming that here) was the key to your successful appeal. I'm just surprised they turned you down in the first place! I'm sorry our government made you work for what you needed surgically but, so glad you had a positive outcome!

This is very good advice: "It only took me 3 months to do three appeals but the key is responding back within a week of the denial. If you take the 30-45 days to do the appeal, it will take longer."

Thanks for sharing your experience!

colorado babe 03-15-2015 11:55 AM

Cynlite. It doesn't matter if the information is on the www. The insurance companies are counting on you not appealing. The info is still reliable and credible and they can't say it's investigational when this info is out there. they want you to give up. If you do, your falling into their web. Fight!

NJ Gene 03-15-2015 12:28 PM

While you are on this subject, I have a question. Is there anyone out there who needed two levels of ADR done, but insurance would only pay for one, but they personally paid out-of-pocket for second? I was told by the Pennsylvania surgeon that insurance companies may be okay with that if you let the ins company know upfront that you're going to do that.

I got the impression from another surgeon I spoke to that it is all or nothing.

Cynlite 03-15-2015 12:31 PM

Colorado Babe, I intend to fight! Thanks for taking the time to share your experience and give me your suggestions.

My priority right now is my health because I feel so terrible everyday. I have already resigned myself to the fact that my insurance company will most likely require me to appeal. I've researched their guidelines and while they say they will approve the ADR, in the approval process if I have had a prior surgery, they will use that to decline the request. There is no way I will have a fusion just because it's convenient for them. I would only have a fusion if my body indicated that was my only choice. I already have a surgeon in Germany that believes I need a two level ADR so physically, ADR is my best route IMO.

Of course, I will find out what the out of pocket cost is to have my U.S. surgeon do the surgery. If he convinces me that the Mobi-C is a good option for me over the M6-C then of course, I would prefer not to travel to another country to have surgery but, I have to consider all the factors. One European surgeon has implanted over 1000 and the other over 2000 so, there is that to consider too.

I will have to do the appeal after I see the U.S. surgeon in a week. But, I know that I can't wait 3 months or longer for an unexpected outcome. I'm extremely concerned about my health right now as it continues to decline. If the insurance company turns me down and turns down the appeal, I will most likely move forward with my plans to have the surgery done in Europe (assuming their cost is less than the U.S) and then fight the insurance company afterwards full knowing that they will probably use surgery in a foreign country to turn me down in future appeals. I have tried to plan out my future for all possible outcomes when it comes to this surgery. I also may speak to a lawyer if it gets too messy later in the appeal process. I just have to take this a step at a time.

I need a lot of luck and prayers right now! Thank you so much for your input. I really do appreciate hearing from people who have been through the surgery, won the insurance battle and recovered from debilitating pain! It gives me hope :)

NJ Gene 03-15-2015 03:06 PM

Cynlite, One thing I'm seriously considering (if I have to pay out of pocket) is using Dr. Blumenthal at Texas Back Institute (in Plano, TX) He uses multiple devices (including the Mobi-C) and his cost out-of-pocket for 2 levels (hospital, anesthesia, surgery, etc) is just under $30K. If you happen to have insurance that has out-of-network benefits, some of that may be covered your policy.

Since you need your surgery ASAP, you could probably pay out-of-pocket with him and if you have the proper insurance, fight with them later. If you go to Europe the cost will be more than $30K (that doesn't even factor in the cost of flights) and follow-up in the U.S. will be more difficult. Finally, there is much less likelihood of insurance covering you overseas.

Gene

Cynlite 03-15-2015 04:22 PM

Thanks NJ Gene! Unfortunately, my insurance does not cover me out of state or overseas LOL. Hopefully, the Barrow Institute will charge roughly the same as your surgeon and the one up in Washington. If that's the case, then I agree with you on most of your points.

One of my reservations is that Dr. Bierstedt mentioned that the M6-C is a better disc than the Mobi-C for protecting the facet joints going forward. It doesn't allow for over extending the natural movement of the body. Sorry, I don't recall the medical terms. Anyway, I don't want my poor facet joints to get arthritis before their time.

I'm really curious to see what Dr. Zeegers has to say because he is going to review ALL of my prior medical history before giving me his opinion. It's been quite a job pulling everything together for him. I'm going to send him his consult fee on Monday. He's already started reviewing my case without payment! He's really a wonderful person and surgeon. Check him out on Facebook if you want to read more about his success stories. Right now, he's consulting on my case. Later, we'll see where this leads.

Thanks for your thoughts and input. I appreciate all the help I can get figuring out this puzzle.

Dema 03-15-2015 10:12 PM

Cynlite, you have our prayers wishing you choose the right surgeon and be pain free very soon.

NJ Gene, I was told about splitting the payment with the insurance acouple of years ago for a 2 level ADR, but since the Mobi-C has been received FDA approval since, I would think the insurance should pay for both levels,at least when done here in US. Though I think some people here had success with insurance covering ADR's done in Europe.

Dema & Raouf

Jerry5 03-16-2015 07:50 AM

cervical
 
If this is the cervical, the US FDA last August, approved the two level Mobi-C

So the insurance should not refuse this treatment.

Cynlite 03-19-2015 02:46 PM

Spinal Nerve Functions Picture
 
http://i62.tinypic.com/2hoh949.jpg

Cynlite 04-04-2015 01:53 AM

Some of the Top ADR Docs
 
This has been posted on ADR Support before but, I thought I would put it on my thread for those looking to stay in the states for ADR surgery. Some of the surgeons names show up on this site so, first hand experience from their patients can be read about here if you do some looking around.

36 Spine Surgeons Performing Artificial Disc Replacement

colorado babe 04-06-2015 09:09 AM

Thanks for posting a current list. Will keep it for my files!

Cynlite 04-06-2015 12:01 PM

You are most welcome :)

It appears that Dr. Pettine did a two level Mobi-C on your neck. He seems to be one of the more experienced surgeon's in the country. I just finished looking at his website. I'm curious how the stem cell injections helped you with your fibromylagia and surgery. Did you continue with them? I read that you thought it improved your healing process at the time.

I hope you are continuing to recover well from your surgery and that life is good. Take care, :angel:

colorado babe 04-08-2015 09:05 AM

Quote:

Originally Posted by Cynlite (Post 110046)
You are most welcome :)

It appears that Dr. Pettine did a two level Mobi-C on your neck. He seems to be one of the more experienced surgeon's in the country. I just finished looking at his website. I'm curious how the stem cell injections helped you with your fibromylagia and surgery. Did you continue with them? I read that you thought it improved your healing process at the time.

I hope you are continuing to recover well from your surgery and that life is good. Take care, :angel:

Yes, Dr. Pettine performed my two-level Mobi-C and all is going very well. He also did the stem cell procedure on me as well (for chronic pain and to help with healing after surgery) a few months prior to surgery. I am doing great and all my symptoms previously with the chronic pain is gone and I truly believe the stem cells helped speed up the healing process.
I will be interviewed once again by channel 9 next week. The reporter is coming to interview me at my house. I'm hoping it doesn't snow again before the visit. If you haven't seen the first TV interview, you can view it at:
http://link.brightcove.com/services/...=4072872709001

JeffR 04-08-2015 10:30 AM

If I was in the US facing surgery without insurance IN ALL CASES then I would go to Europe in a heartbeat. The surgeons there have better discs available, the best have done more ADRs than US doctors and the cost would be less in most cases (at least it was WAYYY less for me), i.e. 75K in the US versus 43K in Europe (this was a while back though and I understand prices have gone up considerably).

I think the fear of lack of follow-up is overstated, you just need to find a sympathetic doctor which isn't that hard to find - many doctors will be very curious about your new device and would welcome the chance to learn something. The odds of something going south post surgery are VERY low and I don't think it really matters if you are here or there if that occurs, you still will have to pay out of pocket and likely travel.

-Jeff

scoop302 04-09-2015 12:22 AM

I would have to agree with Jeff. My surgery in Spain was about $47,000 for everything. Three first class tickets (my brother and mother had a vacation) and that was at 1.43 dollar to euro. If I had the surgery done here, assuming that I could even have ADR, it would have been over $80,000. Most would not do it because of the previous fusion and the amount of damage consisting of bone spurs, narrowing in the foramen. I am currently seeing an orthopedic surgeon who would have done 2 mobi-c's. I didn't ask about price, since there was no point, but he said it would have been more. The only other doctor that would do it, uses either Bryan or pro disc which I would never do. I need to have two done in my back. Here it would be hybrid, fusion and pro disc. I know it will be more than overseas, but after going to Spain, when I need to do it, I know I will go back. You cannot put a price on experience and this isn't a hip or knee, there really are not any do overs. Plus, I know scars are cool and all, but I look like I tried to hang myself, I don't need to continue the scar all the way around. Although, this past halloween, I painted some stitches on it and gave candy to the kids and shocked their parents.

Romakis 04-09-2015 08:25 AM

Quote:

Originally Posted by scoop302 (Post 110074)
Although, this past halloween, I painted some stitches on it and gave candy to the kids and shocked their parents.

Only Spinies can be so cool :D:D:D

NJ Gene 04-09-2015 11:10 PM

Quote:

Originally Posted by JeffR (Post 110066)
If I was in the US facing surgery without insurance IN ALL CASES then I would go to Europe in a heartbeat. The surgeons there have better discs available, the best have done more ADRs than US doctors and the cost would be less in most cases (at least it was WAYYY less for me), i.e. 75K in the US versus 43K in Europe (this was a while back though and I understand prices have gone up considerably).

I think the fear of lack of follow-up is overstated, you just need to find a sympathetic doctor which isn't that hard to find - many doctors will be very curious about your new device and would welcome the chance to learn something. The odds of something going south post surgery are VERY low and I don't think it really matters if you are here or there if that occurs, you still will have to pay out of pocket and likely travel.

-Jeff

Jeff, I might be the exception to the rule. I'm having one level done at TBI for $22,375. That covers the surgery, anesthesia, one night in hospital, follow-up, etc. It does not include travel and lodging, but that's obviously much less staying domestic vs overseas. I will of course take a nice tax deduction when I prepare my 2015 taxes.

Gene

JeffR 04-10-2015 12:14 PM

That's a very good price from what I know. To put that in perspective when I had a discogram through TBI the company they subcontracted to tried to tried to fleece me for 18K saying that was the standard rate for discograms. I had it in writing that the whole procedure was going to cost 3K so they eventually relented, but it took a while.

-Jeff

Cynlite 04-12-2015 07:33 PM

Colorado Babe, I just saw the link you posted to your interview! I'm so happy the two procedures restored your life. That is just truly amazing! Thanks for sharing :clap:

Cynlite 04-12-2015 07:39 PM

Private pay prices
 
Thanks to everyone who shared their surgery prices! If I get enough of them on here, I'll put together a spreadsheet to post both here and on my international thread. Here's what I need:

Date
Cost
Procedure including type of disc
Surgeon
Location
Hospital

I think that will cover all the important info to share.

Cynlite 04-12-2015 09:02 PM

ADR Costs I have so far
 
http://i62.tinypic.com/317hbw6.jpg

colorado babe 04-13-2015 12:08 PM

I can give you the breakdown for my two-level cervical Mobi-C (C5-7) and fusion at L5-S1. Sorry but I had two procedures done. I'll include what was billed and how much UHC allowed.

Northern CO Anesthesia Professional's: $2, 646.00 Allowed: $521.41
Northern CO Surgical Association: $3,835 Allowed: $889.61
Rocky Mountain Associates and Ortho MED PC (Assistant Surgeon): $2880 Allowed$244.97
Poudre Valley Hospital: $110, 259.65, Allowed: $21,786.27
Rocky Mountain Associate & Ortho MED PC: 15, 589.00 Allowed: $2,420

Total paid by insurance: $25,861.85

I was in the hospital for 2 nights.

Cynlite 04-13-2015 12:25 PM

ADR Costs I have so far
 
Thanks Colorado Babe for your input. Here's the revised spreadsheet:

http://i62.tinypic.com/317hbw6.jpg

drewrad 04-13-2015 01:10 PM

Drewrad: $50,000, 3 level hybrid, L3/4/5 M6L, L5/S1 fusion. Clavel.

JeffR 04-13-2015 02:13 PM

Colorado Babe's surgery cost was ~132K not ~26K. The ~26K was just the amount that insurance covered.

Cynlite 04-13-2015 02:43 PM

JeffR re insurance
 
My understanding is that the hospitals charge an inflated amount knowing what is the allowable amount. They then write off the difference as a loss. Colorado Babe did not have to pay the difference so, the inflated amount is just air for tax purposes the way I see it. If I'm wrong, I'm happy to make the changes on my spreadsheet but, I'll leave it the way it is for now. Thanks for your input on this Jeff. I appreciate everyone's input. I'm doing this exercise to help others so they don't have to look so hard to find the data we all worked hard to get. :eek2:

Thanks drewrad. I've added your information!

http://i62.tinypic.com/317hbw6.jpg

JeffR 04-13-2015 04:01 PM

Honestly a hybrid procedure out of pocket is definitely over 100K in the US. I was quoted 125K for a hybrid with two prodiscs from TBI and they tried hard to get the price down - and that was 3 1/2 years ago.

The amount insurance covers is NOT what colorado babe ended up having to pay, i.e. if insurance covered 26K and the procedure was 132K then she had to pay 106K out of pocket. Putting the price down as 26K on your sheet is misleading since no one is going to pay that amount for that procedure even with insurance (it is just what the insurance company was willing to cover).

Cynlite 04-13-2015 04:42 PM

Jeff, I sent Colorado Babe a message to see if she can clear this up for us.

colorado babe 04-13-2015 05:19 PM

I had a two level Mobi C at cervical and a fusion at L5-S1!

colorado babe 04-13-2015 05:22 PM

Quote:

Originally Posted by JeffR (Post 110161)
Honestly a hybrid procedure out of pocket is definitely over 100K in the US. I was quoted 125K for a hybrid with two prodiscs from TBI and they tried hard to get the price down - and that was 3 1/2 years ago.

The amount insurance covers is NOT what colorado babe ended up having to pay, i.e. if insurance covered 26K and the procedure was 132K then she had to pay 106K out of pocket. Putting the price down as 26K on your sheet is misleading since no one is going to pay that amount for that procedure even with insurance (it is just what the insurance company was willing to cover).

The amount Insurance paid on the spreadsheet is correct. I only paid $25.00 Jeff.

JeffR 04-13-2015 05:27 PM

Quote:

Originally Posted by colorado babe (Post 110167)
The amount is correct. I only paid $25.00 Jeff.

$25.00 is pretty cheap. :P

Is the $25K what YOU paid our of pocket (and insurance paid the rest), or what the insurance company paid on your behalf (and it cost you nothing)? You said earlier it was the amount paid by insurance which is why I was/am confused...

Cynlite 04-13-2015 05:28 PM

ADR Costs I have so far
 
Thanks for the updates. Hopefully, I have all the information correct now but, if I don't please let me know. I updated the information in all places I put the spreadsheet so people don't run across older copies and rely on that information.

BTW, Colorado Babe, I think you are winning the price war on cervical disc replacements. You just beat out our lowest European price. It's really good information to know that your hospital and Top Doc accepted that amount in the U.S.! I think that the amount "allowable" was determined by Medicare but, it could have been a negotiated rate by your insurance company. I'm not sure every hospital and doctor would accept that amount since it's a negotiated price but, still really good leverage.

My insurance will not cover me out of state because it's a Medicare HMO (I'm on disability) so, I think an appeal would most likely be useless since this restriction is stated up front. I am only covered out of state if it's an emergency. However, I may give Dr. Pettine's office a call when all is said and done. Now, my big question will be is it worth paying the extra money going to Europe to get the M6-C?

colorado babe 04-13-2015 05:29 PM

Quote:

Originally Posted by JeffR (Post 110168)
$25.00 is pretty cheap. :P

Is the $25K what YOU paid our of pocket (and insurance paid the rest), or what the insurance company paid on your behalf (and it cost you nothing)? You said earlier it was the amount paid by insurance which is why I was/am confused...

Insurance paid it Jeff. My share was $25.00. Not sure why you are confused.


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