Discogenic Pain and Insurance for ADR
 

Hello everyone,

I am trying to gather some information to help our decision making going forward. My 42 yo husband has chronic debilitating pain in his neck, shoulder, upper back that is non-specific. We have seen countless doctors and are now told it’s discogenic pain. One doctor suggested that before we go through with the cervical discogram, we should try and determine if insurance would pay for the surgery. The discogram is not covered ($3500) by any carrier, but we specifically have Aetna. We have reviewed their policies bulletin and struggle to see if we qualify for ADR surgery. No real radiculopathy symptoms. Some mild and moderate herniations and some annular tearing, but no clear neural or cord impingement (c5-6 has the biggest herniation with a tear).

Question: What’s the likelihood of ANY insurance carrier paying surgery for discogenic pain that doesn’t really qualify in the normal impingement/radiculopathy sense? We may switch to BCBX TX in January and their policy bulletin is similar in needing to meet “all requirements”. Also, how can we really apply for the surgery if they won’t cover the discogram? Can we submit the results for a test they don’t even believe in? What records are included when a submission is made? Can we guide/help the submission process?

For simplistic purposes, assume this would be a single level ADR. I think the discogenic pain diagnosis is going to be difficult enough and if it’s multilevel we are totally hosed.

Please offer your experience/guidance based on your own or someone else’s report regarding what kind of things we should expect for insurance coverage/denial. Also, if you have any opinions on whether we would be better off with Aetna vs. BCBS TX, please let us know. We could save some $$$ switching to BCBS but paying for surgery out of pocket sounds ridiculous.

Thank you!

I hope Aetna pays for Discogram...I had it done in June...and have only seen a bill from the Anesthesia guy, not the pain guy who did the procedure. PS: mine was for lumbar. I also need 3 discs in my neck but waiting on approval for the 2 in my back first.

We scheduled the discogram yesterday for this Thursday and the office said that Aetna doesn't cover it (they cover lumbar, but not cervical), so they don't even bill it out at all. I did read their medical documents and I kind of knew that, but was hopeful anyways. They said they have arranged a cash negotiation with one of the surgery centers where these are performed, so we have to use that specific location. The grand total is $3550. Yikes. I was warned by others, and they were right. It's just so much money for a stupid painful test.

Cervical discogram
 

Sorry you are having to pay for the discogram, but excited that you are moving forward to an answer for a solution! I wasn't aware that most insurance companies will not pay for cervical discograms--why is that?

I will be thinking of you guys on Thursday and looking forward to hearing the results! :)

We had the discogram for my husband yesterday at 4 levels and it was clear and decisive that C5/6 is the bad disc. That's the one that has always looked the worst on the MRI, but without actual impingement or radiculopathy was just too questionable. We meet with the surgeon on Monday to schedule ADR with the prodisc. His pain has been somewhat elevated, but not substantially so since the procedure. Thankful for that!

I'm not sure if I can post this here, but some people have indicated interest in understanding the insurance coverage for the discogram. Here is the cut and paste info from Aetna:

Clinical Policy Bulletin:
Discography


Number: 0733
Policy History http://www.aetna.com/assets/graphics/bullet_link.gif Last Review: 11/30/2012 Effective: 08/10/2007
Next Review: 09/23/2013

Policy

1. Aetna considers lumbar provocative discography medically necessary for evaluation for disc pathology in persons with persistent, severe low back pain (LBP) and abnormal interspaces on magnetic resonance imaging (MRI), where other diagnostic tests have failed to reveal clear confirmation of a suspected disc as the source of pain, and surgical intervention is being considered.
   Aetna considers lumbar provocative discography experimental and investigational for all other indications because its effectiveness for indications other than the ones lsited above has not been established.
2. Aetna considers cervical and thoracic provocative discography experimental and investigational because there is insufficient evidence to support their effectiveness.
3. Aetna considers functional anesthetic discography (involving injection of anesthestic directly into the disc) experimental and investigational because there is insufficient evidence to support its clinical utility.

It really did cost us $3500 exactly for the test. Unreal. And that was the negotiated cash rate!!!