Hello everyone. I am new to this site as of a few days ago. I am currently handling all of the details related to my wife, Katie. She has had lower back pain for over 3 years. We had seen 4 different doctors for a diagnosis and had received different answers ranging from "I don't know" to "a growth in the lower back, snaking into her spinal column". After going through physical therapy, pain management, swimming, wearing a custom-made brace, pain-killing injections, and different oral narcotics, (none of which helped), we saw an orthopaedic doctor. He consulted us in March, and after examining her and her MRI's, he diagnosed her with significant DDD at L5-S1, and told us she was a perfect candidate for the ADR procedure.

The doctors office submitted a pre-Certification form for the ADR procedure, which was lost in the shuffle for a month and a half. Someone in the insurance company sent it to the wrong department with the wrong doctors name attached. After we straightened out the mess, the pre-cert was denied, which I know will come as no shock to any of you.

Since then, we requested that the doctor call the insurance company to perform a peer-to-peer appeal, which he did. This too has been denied.

I am now in the process of composing a written appeal. After reading the posts of other members and knowing what they have gone through, I wish to laden this down with as much research and back-up evidence as possible.

Can anyone point me in the right direction of where to search for articles and studies done on the ADR procedure?

Your help is much appreciated. Thank you.

Drew

I also have been where you are. I just received my third and final denial. I had two denials from the insurance company itself, and then went to my state Insurance Department. In my state (NY) they use an ombudsman program, which in my mind is useless. I sent in information, my doctor sent in information, and I got my negative response last Friday.

There was a panel of 3, I needed a majority, I got 1 yes and 2 no's. I have no idea where to go from here. The reasons given by the no's were bogus, and I did not feel that my doctor did as much as he could to help me. There was apparently items missing from him. I hope that you get a better result. Apparently your doctor is more involved with his patients than mine was.

I did find that the disc manufacturers themselves were very helpful. The charite disc is manufactured by DePuy Spine, a division of Johnson and Johnson. They have an entire department entitled "Payer Relations"! I called them on a whim (1-866-347-2523). Part of the information they e-mailed me was an outline of how to write your appeal, what to say.

Not that anything I did made a difference. Maybe you will have a different result. And in any case, you won't feel so alone in all of this.

Welcome, Drew and Katie!

We're glad you joined us and we hope you will find some answers here. Especially important to your wife is the fact that you are obviously totally invested in helping her through this. Several of our members have no such support system and we all realize how important and valued a good helper can be. Good on ya!

First of all, scan through all the FAQ's (bottom of page pulldown menu) to get what info you can there, specific to ADR and related subjects. Then, utilize the search engine (top right of every page) to see what info you can glean that has already been posted on the forum. Much of what you seek is already here and the search engine will locate it. When using the search engine, make sure you select "Search All Open Forums" unless you're sure your topic is only within one forum or another.

There are members here from Mass., including Harrison and myself. Email me and I'll give you my phone number if you want to talk.