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semathes 08-28-2011 06:14 PM

Another newbie denied ADR by BCBS
 
Suffering with degenerative disk disease at L5-S1. No other issues, 49 years, perfect ADR candidate as per current doctors.
Recently denied ADR by BCBS as usual and as per their policy that not enough history exists to prove ADR is better then traditional (fuse) methods, making this experimental.
I have Insurance Warrior book and have read this forum for awhile now.
Currently scheduled for a second opinion before I decide how much battle to wage.
Options are:
1. Do nothing. Really no longer an option. Pain getting harder to manage and have any semblance of a normal life.
2. Get fused. Limit to movement is no worse than current limit. If trouble develops in adjacent disk pursue ADR at that time and place.
3. Wage war on BCBS. They are more experienced at this than I to say the least. I do not have examples to use of them approving others. I do not have literature to refute there claim that long term benefits are unproven. Perhaps this board can help me.
4. Pay out of pocket (kids college fund).

Questions are numerous. Such as:
1. If I pay myself and have any trouble either now or in the future, I assume BCBS will never cover any remedial work and I could lose the house as well as the college fund.
2. Is it possible to acquire secondary insurance, with this pre-existing, for the sole purpose of covering what I know BCBS won't? Anyone done this?
3. Has BCBS ever approved anyone? If so on what basis?
4. Are there any studies I can use against BCBS's experimental basis of denial? Can the long history of work in Europe be used?
5. What are the best reasons to have ADR as opposed to a fuse?
6. Does anyone have experience involving the manufacture (Pro-Disk) in the appeal process?

I'll stop for now. Glad you folks are here but I'm not hopeful of a positive outcome. Unless a light comes on somewhere I don't now what to do next.

Scott

Jstuckey 08-28-2011 06:33 PM

Couple of thoughts-
1. Secondary insurance - From what I know of insurance working in a hospital, your procedure has to be a covered procedure by the primary insurance before the secondary will pick up any of the tab. They won't pay if the the primary says not in the plan / not covered / experimental / blah, blah, blah. I'm thinking revisions or specific ADR related problems would probably be an issue with payment too.
2. I'm obviously a fan of ADR when appropriate - but I'm having L5-S1 fused soon, as it is too far gone (facet damage) for an ADR at that level. If your L4-5 above the culpret is healthy, it may not be a horrible thing to have a fusion there. My surgeon said there is very little movement at L5-S1 anyway, so the stress on the above disc is the most minimal that it could be with a fusion at that lowest point, as opposed to fusions at higher levels. In other words, I don't think it would be the worst thing in the world for a fusion, if your options are limited.

Keep working on it and read, read, read....Send your reports overseas for free opinions. You'll learn a lot.

jss 08-28-2011 11:29 PM

Scott,

Condolences on your condition and dilemma; but welcome!

You know, effective lumbar ADR has been around for over 20 years. Some insurance companies today will deny fusion because ADR has sufficiently better outcomes. It's enough to make you crazy.

BCBS is a conglomeration of insurance companies. So while BCBS-TX and BCBS-Michigan will cover ADR, that doesn't mean that BCBS-Anthem will cover ADR. Yes, many of the BCBS constituent companies have paid for ADR. Which BCBS do you have?

BCBS-TX would not cover my double ADR, though they approved me for a single level.

Quote:

Originally Posted by semathes (Post 90127)
1. If I pay myself and have any trouble either now or in the future, I assume BCBS will never cover any remedial work and I could lose the house as well as the college fund.

I don't know the answer to this one, but would tend to doubt that BCBS would not cover an ADR revision. More and more insurance companies are covering ADR, and it follows to reason that your company might cover ADR by the time, God forbid, you need a revision.

Quote:

Originally Posted by semathes (Post 90127)
3. Has BCBS ever approved anyone? If so on what basis?

BCBS is a conglomeration of insurance companies. So while BCBS-TX and BCBS-Michigan will cover ADR, that doesn't mean that BCBS-Anthem will cover ADR. Yes, many of the BCBS constituent companies have paid for ADR. Which BCBS do you have?

BCBS-TX would not cover my double ADR, though they approved me for a single level.

Quote:

Originally Posted by semathes (Post 90127)
4. Are there any studies I can use against BCBS's experimental basis of denial? Can the long history of work in Europe be used?

I can provide you with my last appeal to BCBS-TX. It includes 91 pages of clinical data from single and double blind studies amounting to over 800 years worth of clinical data that prove the safety and effectiveness of multilevel ADR. Though the appeal is iron-clad, BCBS did not reimburse me. If you want my failed appeal, PM me and I'll tell you where you can download it.

Quote:

Originally Posted by semathes (Post 90127)
5. What are the best reasons to have ADR as opposed to a fuse?

Per Dr Alan Hilibrand's landmark 1999 study, one cervical fusion results in a 25% chance that you'll require a 2nd one within 10 years. It is generally accepted that one fusion, cervical or lumbar, will result in another. Though ADR has yet to develop into a silver bullet for spinal problems, such a pattern has not been shown with ADR.

While there are very good reasons to select ADR over fusion, in many cases there are very good reasons to select fusion over ADR.

Quote:

Originally Posted by semathes (Post 90127)
6. Does anyone have experience involving the manufacture (Pro-Disk) in the appeal process?

I don't have this experience but can tell you that some manufacturers will provide you with a sample insurance appeal upon request. I've seen a few of these and don't know if Synthes provides that sample appeal.

If you're a good candidate for ADR, I'd strongly recommend that you vigorously pursue your insurance company for coverage. In my case I had to have surgery immediately and didn't have the time required to battle BCBS-TX before surgery. As a result, they had absolutely no incentive to reimburse me after the surgery. As my surgery, in Barcelona, cost about half of what it would have cost in the US, I feel that I would have had a good chance of getting coverage had I had the luxury of time before surgery.

Good luck, Jeff

JEVE19 08-29-2011 01:11 AM

Scott,

I am in the process of switching insurance to see if I can get the ADR covered.

Don't know all of the state laws but here in Florida, we were told that we should switch to business insurance. We do own a legitimate corporation. We now have a personal policy.
As it was explained to us, if we get a business policy the insurance company can put up to an 18 month wait on pre existing conditions. But...because our personal policy has been held for 36 months with no gap in coverage, that counts towards the max 18 months. Our personal policy ends in October and the new business policy will start October 1st.
We are going to give it a try. We were told that even if ADR is not covered, the hospital part should be.
The price will go up from $549 monthly for me and the hubby to somewhere around $1,600 - $2,100 monthly.

Supposed to get final info this week.

I called my doctor's office and asked the manager what company they have the most success with as far as getting an ADR approved. We were told Cigna and Aetna.
Specifically told to ask for the Aetna POS 2 PLAN.

I will be able to post sometime in October if this worked.

I was told that BCBS only pays the doctor $2,000 for an ADR single level. They pay double that amount to them for doing a fusion. My doctor told me he has sent many papers to the insurance showing the advantages of ADR over fusion and said that it is very frustrating to him. Was told they will probably not accept BCBS in the future if this does not change.

It's all very frustrating and worse when you live with chronic pain. The insurance companies don't think that having surgery to alleviate chronic pain is necessary?

Find a doctor who will do battle with you.
Some are more willing than others.
I have to friends who have had fusions at the L5-S1 level.
One of them had hers done at TBI 14 years ago.
She is doing fine. Owns a retail wine store.
Says after standing 10-12 hours, she can still get pretty sore and tries to avoid that. She told me that she really hasn't had too much trouble with her fusion.

My other friend was a co worker who had her fusion two years ago. I asked her how she was feeling about it and her answer was "not sure". Sometimes it bothers her more than others. She has a desk job, but she swims everyday and is very active.

So, I guess there are good and bad stories about fusions and ADR'S.

Welcome to the forum. It's a great resource for info, outcomes, and other people who understand which is so important.

Thank Harrison for a lot of volunteer time and effort.
Many knowledgeable people on here and I've had nice support from several members.

laid up doc 08-29-2011 04:41 AM

funny vicki, i'm having to have metal allergy testing to prove to aetna that i CAN'T have an adr... i'm petrified of the metal and would rather have a fusion. if the testing is ok i'll reconsider but... still scared b/c i'm very atopic.

fwiw, the insurance i have is exactly what you've been told to get. have had no problems getting what i need covered including tens unit, epidurals, MRI's. no limit on PT, which is the main reason i've kept is despite the cost. i'm still under my employer's COBRA - am now part time.

JEVE19 08-29-2011 01:09 PM

I wish I had known this back at the 18 month date instead of the 36 month date. Needless to say, I switched to a new insurance man!

semathes 08-29-2011 08:57 PM

more info
 
Nice to hear from caring people who know what this is like.

My insurance is Anthem BCBS through my employer. They just changed to Anthem 1/1/11 so if I would have not tried to live with the condition the last couple of years I might have been covered. Hindsight now.

I'm waiting for another appointment and second opinion. I tried to get the best ADR man around. He claims to have done the most in Houston and teaches others the procedure. However he does not appear to be adamant of ADR vs fusion, at least not enough to help fight Anthem. Waste of his time I guess.

My pain management Dr is adamant however. She says I'll be seeing her again if I get a fusion. She also has said I need to switch insurance companies. Not easy to do with employer provided family coverage.

I think the worst part is trying to figure all this out, pain treatments, PT, the DRs, which method of repair, the insurance issues, grounds for appeal, how much time can I wait, on and on, without knowledge or help, while working, raising a family, living in pain. I would pay someone to help get it handled if such a person existed.

I'm also wondering what Anthem's deal really is? If ADR is cheaper, or at least not significantly more expensive typically, the recovery is quicker, the risk of additional issues decreased etc etc why would Anthem not allow ADR? If they only care about the money, as we know they do, then why not allow ADR? It would make more sense if the ADR cost significantly more. And why would others (Aetna, Cigna, some BCBS) who are also only calculating the dollars have figured it differently?

Harrison 08-29-2011 10:24 PM

“…I'm also wondering what Anthem's deal really is? If ADR is cheaper, or at least not significantly more expensive typically, the recovery is quicker, the risk of additional issues decreased etc etc why would Anthem not allow ADR? If they only care about the money, as we know they do, then why not allow ADR? It would make more sense if the ADR cost significantly more. And why would others (Aetna, Cigna, some BCBS) who are also only calculating the dollars have figured it differently?”
Well stated indeed. I’ve been wondering the same thing since disc replacement trials started in the U.S. eleven years ago! In case you didn't see my presentation on the results of my survey of this community's outcomes, see this presentation to the SAS on this rigorous analysis.

There are many reasons why different insurance companies have their own policies, but most of it has to do with their own organization culture and resources. Some companies “get it” and have better number crunchers and better data.

Still other companies have arguably more resources, and reach different conclusions and draft different policies based on their understanding of spinal diseases and their multiple etiologies. And they do not cover ADR or other new non-spinal treatments. But they don’t share this information with us and they never will – they have no reason to do so – like any other insurer.

I produced a DVD that deals with many of the issues in your post. Did you watch it yet? It may help you with some of these annoying problems. See the non-profit site and video here.

Question: Is your degenerative spinal disease localized to one level?

semathes 08-29-2011 11:08 PM

video just bought
 
Bought the video about 5 min before you posted. Saw the presentation as well.

I am one level only, L5-S1, otherwise excellent health for a previously active 49 year old bald man. All I get from DR's is "ideal ADR candidate".

Keep up the valuable service.


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