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-   -   Two Level ADR U.S. Pay out of Pocket (https://www.adrsupport.org/forums/showthread.php?t=13057)

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.


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