Just a reminder that JnJ Depuy Spine has developed programs to help patients with insurance appeals. On the Charitedisc.com site, you can find a list of insurance companies that cover the ADR procedure. That list is attached to this topic in PDF format.

If you need appeal support with a Charite appeal decision, see this topic.

Hi Harrison

That is helpful. Do you know if anyone has info on Prodisc like this. That is awesome.
Thanks,
Meg

Hi Meg,
There is a toll free number for reimbursement support on the prodisc website. 1-866-223-0508 . There are also several forms and guides for doctors and patients.

http://us.synthesprodisc.com/EN-US/Reimbursement/

Thaks Jessica

I was just enroute to the site and then got yur email. They have come a long way since I last looked!
Thanks for the taking the time.
BTW... did you have insurance coverage? How are you doing now?
Meg

i'm hopefully going to have prodisc w/ delamarter after my insurence starts through my job. this form is gonna come in handy when they start jerking me around after my appointments.
you'll definately be hearing from me round that time harrison.
http://adrsupport.org/groupee_common...icon_smile.gif

Rayray,
FYI… I had a three level Pro-disc with Delamarter. He is an excellent surgeon. I have Aetna insurance and they paid all by about $3000.00.
I had the surgery in October 06 and am 100% better then prior to the surgery. I have some pain at night but each week marks improvement.

Could you tell me what Aetna policy you had that covered the surgery? I am trying to get a policy with them but have been told not all of their policies will cover the procedure and Aetna has not been overly helpful at helping me with policy information.

Thanks!

I have Aetna Choice POS II.

does anyone know if Aetna will cover ADR at Stenum hospital in Munich? thanks!

Hey all, I'll be "trimming" this thread soon. New questions = new topic.

Who paid for your ADR?
 

I would love to hear from more on the surgical outcome forum as to who paid for their surgery? Did they? Or did Insurance? I think this is equally important as denials, so those of us trying to get it know if there is a precedent.

There has been a precedent set in Michigan by several recipients of ADR surgeries done in Germany and paid for by Blue Cross/Blue Shield of Michigan. They originally denied my surgery a couple of times and then paid for it.

I always thought they were a good insurance company and they have taken good care of my employees and their families for many years. I have covered almost all of our employees, their spouses and, all children living at home for the 18 years that I have been the director of the company.

I am very pleased with our insurance carrier.

Terry Newton

In researching how to get my hubs hybrid surgery covered, I did get this list from Prodisc (in late Nov). So far, not many are hopping on board, but that is changing! Most important, it requires a doctor willing to advocate for the patient and prove the proposed procedure is appropriate. Here's the list I have (and hope to add at least one more very soon):

Aetna routinely approves LADR, and it has been approved by Signa in Arizona, Arkansas, Montana and New Jersey, Blue Cross, Capital Health, Great West Healthcare, Gunderson Health, Intermountain Healthcare, Kaiser Permanente, Washington State Employee Health Plan.

That list doesn't mean it's at all easy to get it approved, but it's been done, so it's possible given the right patient and circumstances. Aetna seems the only one that considers ADR like any other treatment and I'm sure there are more... these are just what they were able to tell me that had been told were covered.

FWIW, Great West denied my cervical ADR a little over a year ago. Maybe they approve lumbar ADR?

Excuse me-
 

I'm new here but did someone say that Aetna might cover ADR?
Sorry I'm excited that there is even a slight possibility. Been sitting here brewing all day over the fact that the procedure is not covered in the US since I just found out about the stenum hospital .
My Orthopedic surgeon wants to do the Fusion of c3-4 and c5-6.

Is it a remote possibility that Aetna might cover Cervical ADR?
Does anyone know.
Thanks for all the postings. I have been a long time sufferer and keep "stumbling" onto treatments. The medical community steers you in the direction they want you to go.
The rest I have found out on my own which is BS.
:jacks:

3 level Prodisc C covered by Premera BC in Germany
 

OK, I don't know if this is a news flash or what, but after 2 months of phone calls and documentation, my Premera Blue Cross plan pre-authorized my multilevel ADR with Dr. Bertagnoli in Germany. I had just refinanced my house to send off the payment in the 3 weeks in advance of my surgery, which took place mid-April, almost 4 weeks ago. (very happy with my results so far, BTW). What a relief to know that my daughter can go to college next year. Dr. B's billing staff honestly didn't know what to do with my pre-authorization letter - they knew it was legit, but I gathered they were surprised that I only had to pay just over $400 in co-pays.

So here's what I know: If you have BC and your card shows a suitcase that has something inside it (like PPO), you have international coverage. I made a lot of anonymous, or 'hypothetically speaking' phone calls before submitting my request for coverage. I took the advice found here and on ProSpine's site, and got plenty of support from Tom Vicknair, who works with Prospine to assist the uninitiated. In the end, it all worked out. I still don't know exactly what did it. I argued that it would be cheaper, I was eligible for overseas coverage and should be held to the standard in the country where it would be performed, and I was willing to incur all the costs of rendering myself to Germany, including any follow-up care and expenses. I also sent my letter of medical necessity, abstracts of Dr B's research, peer-reviewed studies that show that ADR is of the greatest benefit for people like me who need multiple levels replaced. I also added that it would be at least 1/2 the cost of fusion here. Of course, it's possible that none of these factors had anything to do with thier decision, but I think that the major savings to them, and my willingness to go to where FDA approval was meaningless were what did it. I guess I'll never know.

One more thing: Be persistent, but polite, and call back to speak with a different CS rep until you talk to someone who seems sympathetic. Ask for advice in getting it approved. I was coached in what to include to support my claim, and I went to work gathering all the documentation I could. Also, Premera is my secondary insurance, and they told me at the onset that they don't pre-authorize for secondary and I would have to submit the bills after the fact. I told them that I had already been denied by my primary and that I didn't have the funds to do it that way. I had given up. Then I made that last call, just hoping that maybe - somehow - some miracle would occur. The rep I worked with was very supportive and seemed genuinely thrilled to tell me it had been approved and the pre-authorization letter was being prepared. So don't give up!

Hope this helps.

Moni, Koroni....Holy Macaroni!
 

Hi Moni,

Yes, see the first post in this topic -- Aetna has covered one level ADRs for some time -- starting with one-level lumbar ADR. I honestly have not see their stated policy describing cervical ADR, but some patients have been already covered for that! They have also covered hybrid procedures (one ADR, one fusion). I cannot confirm if they have covered two-level cervical ADRs.

Koroni, that's great news and not something you hear every day! It's great you have a PPO. If one can afford these kinds of plans, it's definitely a better plan to have.

Aetna's Clinical Policy Bulletin #0591 outlines the FDA approved lumbar and cervical disc replacement as medically necessary (after 6 weeks of conservative therapies) for a single level only. The CPB was updated 3/10/09.

Bob

Anyone had luck with BCBS covering in Germany
 

I recently had ADR surgery in Germany. I had the Maverick device placed. I understand that the FDA is close to approval, is this true? I am looking for any advise to help with my insurance appeal letter!

Thanks,
Sondra

Has UHC EVER paid?
 

Does anyone know of even one documented case in which UHC has paid for ADR either in the US or abroad?

BCBS Worldwide
 

Koroni:

Wow! Reading your post gave me inspiration. We are trying to to exactly what you did, get BCBS Worldwide to pay for a single level cervical ADR in Germany through Dr. B. Do you have any additional insight? Maybe a person whom you spoke with specifically? We have been turned down 1st prior auth via Regence Blue Shield Washington and are trying the worldwide loophole (suitcase). So far BCBS world has said that this is not covered as we have already been turned down by our local carrier.

Thoughts anyone?

Terigrx

Medicare plus normal add-on medigap policy paid for hybrid (Prodisc/fusion). :wiggle:

Cervical Artificial Disc -- Friendly Insurance Companies
 

The following insurance carriers have issued a positive coverage decision on the Prestige Cervical Artificial Disc:

Aetna-National
Avera Health – SD, IA, NE
BCBS Horizon – NJ
BCBS Illinois
BCBS Montana
BCBS New Mexico
BCBS Oklahoma
BCBS South Carolina
BCBS Texas
Broadspire
Brown and Toland IPA – CA
BSBS North Dakota
Builders Insurance Company – NV
Community Care of OK – OK
Cox Health-MO
Dean Health Plan-WI
Employers Insurance of Nevada – NV
Gunderson – Lutheran Health Plan – WI
Highmark BCBS – PA, WV
Lovelace Health Plan – NM
Medical Mutual - OH
Montana State Employee Fund-MT
Motion Picture Association-CA
ODS Health Plan
Pacific Source-OR
Physicians Plus – WI
Premera WA, AK (also administrators for LifeWise AZ, OR)
Priority Health of Western MI – MI
Public Employees Benefit Program – NV
Public Employees Health Plan of Utah – UT
SelectHealth – UT
Willis-Knighton Health Plus – LA
Writer’s Guild-CA

Source: 1-800-446-1234 or visit www.cinn.org. Original article here.

Hi Deborah,

Was this surgery done in the US or abroad?

Nanci

Hello Harrison, First I am not sure how you always 'tirelessly' help others. I am amazed at the good you work here. Enough shmoozing. I have a favor to ask, I was going to ask someone if they know of doctors and insurance companies in the U.S. that will perform ADR and realize that is a much repetative question. I saw this link, it took me to a PDF file that showed AETNA with a ruling that says the 'do?" pay, but the link was no good.

I work for the Boeing Co. and hold Aetna BC BS, I wonder if you may know anything about this in the Pacific NW / Aetna etc?

Thank you very much

Hey Lammie, thx for your kind words and also letting me know about the link. We've had several folks from Boeing pass through here (one donated his super-duper home computer system to this foundation) and are good people and may be able to help you. Also, you and I can talk offline (pls email pr PM me your # and I'll call you in the next 3-5 days).

In the meantime, if you search the Aetna site, you'll find some helpful information:

Clinical Policy Bulletin:
Intervertebral Disc Prostheses
http://www.aetna.com/cpb/medical/data/500_599/0591.html

And others as well:

Spinal Surgery: Laminectomy and Fusion
Aetna considers cervical laminectomy (may be combined with an anterior approach) medically necessary for individuals with a herniated disc when all of the following criteria are met:
http://www.aetna.com/cpb/medical/data/700_799/0743.html

Back Pain - Invasive Procedures
Aetna considers any of the following injections or procedures medically necessary for the treatment of back pain; provided, however, that only one invasive modality or procedure will be considered medically necessary at a time.
http://www.aetna.com/cpb/medical/data/1_99/0016.html

Are you saying that in 2006 aetna paid for you to have a 3-level Cervical ADR?

please clarify where this discussion goes..
 

Hi

I noticed that the popular question "who is paying for adr?" is in the forum Insurance Hell and The Big File. Shouldn't that discussion be taking place in one forum only?

I see that Aetna has a good track record in covering ADR surgeries. Is it possible for anyone to join this company? I realize the premiums will be high but if they cover ADR it will more than pay off.

adr friendly - not
 

I have received notification from BCBSIL that ADR is still considered experimental, since no long term data is available to prove that is is BETTER than fusion. BCBSIL will NOT cover any costs associated with ADR procedure.

Approval Letter, and/or Appeal Letters - BCBS - CA
 

Does anyone have copies of Approval letters from Anthm/BCBS of California, for Cervical ADR?

I would very much like to have some names and examples of approvals for my appeal.

If you have an Appeal letter that worked with Anthm/BCBS of Californis, I would be interested in that as well.

Feel free to email to: brianw6212@gmail.com

Anthem BCBS hell(p)
 

I would like to join forces with anyone who has experience with Anthem BCBS or any other BCBS for that matter.

I'm in need of any successful coverages, appeals, court cases, etc. for lumbar ADR.

Insurance re-imbursement for ADR w/prior fusion?
 

I have heard that some will pay 50% of what Medicare will cover, but what about next to a prior fusion? Has anyone here heard of an insurance company at least covering the Discectomy portion. They would still have to pay for that part of it with a fusion. Just reimburse the surgery cost and let us pay out-of-pocket for the ADR device. :p

Not Cervical
 

But I would talk to your doctor about a Two Level Mobi-C, maybe you can have one of the Fusions removed, or above or below, or above and below, the mobi-c is approved for two levels.

The insurance is real funny, they will fight like the dickens, and say it is NOT approved, then go back at them, AFTER you have it done, and they will reimburse.
Risky, but it does work, in some cases.

First, Talk to your doctor about the Mobi-C, have them submit the paperwork to the insurance.

Bcbs tx
 

Just wanted to post that BCBS TX approved my 2 level cervical ADR with the Mobi-C, and it took them less than a week to approve.

not if you have the slightest Adj level ddd
 

mobi-c will be great for two level but if the disc above/below are even iffy, I would want the m6; that said, insur wil pay for two level mobi-c so I'd go for it! I can't do it though with a prior fusion. Blumenthal's Pat. Coord said I was not a candidate.

i have had doctor tell me that fusion can't be reversed
 

Then I read about Dr. Katzman in FL. and Dr. Kenneth Light in CA. so are they for real? I think if I got the M6 at C 6/7/T1 then had the PEEK cage removed at C 3/4, I might have my life back. :jacks:

Should you even try to get pre authorization?
 

Or just go have it done anyway and beg later??? That way they can't say, "we told you :nono: and you did it anyway, now you want us to pay"

Pre Authrorization
 

Cheryl,
Go ahead and send the MRI/xrays to Bierstedt, (there are others) (the USA does not allow the M6 to be implanted, yet) and get the recommendation from them, submit this to your insurance.

If they deny, they most likely will, then if you can afford it, take it out of a 401 or some other savings, pay for it, then send the Bill to the insurance, for reimbursement.

Most likely they will deny this, but use all your apples, tests, doctor visits, medications, trouble at work, trouble in life, list all, list all the problems, then APPEAL, and APPEAL again.

All the best, and best of luck, the M6 is the best choice, unless you can have the mobi c placed at the lowest level that is giving you trouble(C7T1), then fuse further up, from what other people that have cervical have told me,
Maybe do a hybrid, one level mobi-c, then fusion, or cage, then another level mobi-c then another fusion, this would be 4 levels?