I would like to start a list of people who still have been denied ADR surgery by their insurance company.

What city do you reside, how many levels do you need, and who is your insurance company that denied you. Please specify if you are a workers compensation case because that is a whole different animal.

I am curious to know how many people with single levels still aren't being approved or are they only ones with trouble the ones with multiple levels?????


Anyone interested in posting your information?

Maybe it would be good to also include those that have paid out of pocket to go to Germany because they were denied by their insurance company.
re: lawsuit...highly unlikely in light of another thread discussing ERISA. Still good info to list what companies are not paying up!

I'll start,

Need 2 levels, L4/5 and L5/S1. In 2005, was turned down by Pacificare/UHC PPO for 2 level Charite. Insurance was employer provided insurance from when I used to work in San Diego, CA. Later also denied for a combination Charite at L4/5/fusion L5/S1, same insurance via fed and state extended COBRA while living in Milwaukee, WI. Fusion was tentatively approved but not the Charite portion. Currently reside in Milwaukee, WI. Exhausted all appeals, including appeals with CA Dept of Ins.

me me me i was denied a single level adr charite blue crap.
chuck

Put me down........denied 3X's United Health Care - 2 levels.
I support your right to petition. Let me know if I can help in any way.

Blue Cross Michigan denied 2 level Charite discs done by a surgeon approved and on Harrison's list of Charite surgeons. I went to Germany and paid out-of-pocket for 4 level ADR.

I sued the homeowner's insurance and Blue Cross maintained a lien against the suit. In order to get rid of the lien I had to waive the right to appeal. Nifty.

Terry Newton

Denied by Cigna PPO in California. went to Germany, now pain free and happy.
I hope the insurance geek that denied my coverage has a bad back......let him suffer.

Brad

Denied by Empire Blue Cross Blue Shield for a 1 level Charite ADR at L5-S1. Currently on my 2nd level appeal & keeping all fingers, toes, & eyelashes crossed that I will get the denial overturned! http://adrsupport.org/groupee_common.../icon_wink.gif

I was denied a single level L5/S1 Charite from United Health Care.

I was later approved by Aetna when I switched insurance companies.

Denied by Great West Healthcare for a 2 level lumbar ADR L5/S1 L4/L5

I have been denied by Blue Cross Blue Shield of California. I am about to start the appeals process and am waiting to get a copy of Dr. Lytton William's letter so that we can be in sync. I did find that Prodisc has a place on their website for others in the appeals process and an 866-223-0508. There are Patient appeal letters and surgeon resources. Not sure if this will help my case or not but I am open to suggestions.

So LBP
have we found a lawyer yet For the class action law suit?
i think it's time to teach those idiots a lesson.
no?
chuck

Chuck,

You know I'm in. Denied by Highmark Blue Cross/Shield for single level Charite/Prodisc.
Went to TBI for surgery on 2/8/07. I live in Pittsburgh, PA. Still in the appeals process but I do not expect anything.

If you don't mind Chuck I will make an inquiry with my attorney this week. Have some other business to discuss and he may have some good info for me. He works for a pretty big law firm. I will be glad to pass the info on to you.

Dave

david
that sounds like a plan.
it surely would not hurt to try to find someone.
and if i cant slam them in the lower back with a 2 by 4 then we must become there worst nightmare.
chuck

if insurance company must pay for gov employees if fda approved what gives them the right to change for the private insured i want to see them tell a fed judge that the fda branch of gov is useless.
chuck
p/s its a double standard that must go if its not fda approved then they say no it's not approved.
and if its fda approved and they dont want to pay it becomes experimental. GRRRRR

HEALTHNET may soon pay for Prodisc adr! We were denied by HealthNet today for my husband's two level ADR; however, when HealthNet contacted Dr. Yue's office to inform them of the denial, HealthNet said that they are considering changing their position on covering these procedures, and said to tell us to appeal! Dr. Yue's office has never been told anything like that from any other insurance company! I'll keep you all posted if I hear anything else.
-Kim

Where are you on your list I want to join!!

posting on this thread with relevant info makes a list

Denied by BCBS of Alabama. Went to Germany paid out of pocket for 3-level cervical. Still appealing. Sign me up for the lawsuit.Not workers comp.

I have been denied by
Health Link and Mercy Medical Group.
I have only one disc L4 L5.
It is not workmans comp.

3 appeals denied by United Healthcare last year and initially this year for 2-level Prodisc not b/c multilevel but b/c UHC claims experimental/unproven treatment for DDD. I paid out of pocket with Dr. Delamarter; UHC denied coverage on the date of my surgery. B/c self-funded plan through my employer I was not able to appeal to the CA Insurance Commission or the CA Dept. of Managed Healthcare. I am still in appeals process for reimbursement but do not expect that will happen. Not workers' comp.

I'm in Minneapolis, with HealthPartners, self-funded plan thru spouse's employer. Denied 3 appeals for 3 level lumbar ADR. Paid out of pocket to go to Germany for Dr. B. Not worker's comp.

I am in Illinois.
cigna ppo is my primary carrier.
2 appeals denied.
bc/bs il is secondary carrier.
2 appeals denied.
ADR Charite device at l3-l4, "hybrid" application combined with 2 level fusion below at l4-l5-S1.

Was denied as considered experimental technology. Also because it is outside the FDA approval criteria as being used at l3.
FDA approval for charite is for single level from l4 to s1 and thus my surgery did not meet specifics.
I am not a work comp case.
4 level fusion still pending approval they are also fighting on that one!


ck

denied and used all appeals with blue crap of penna.
IBX blue crap. Self paid to go have dr. b preform a single level at l5-l6.
after returning home submitted again to blue crap as out of network and was told i was to receive payment then they turned around again and denied the entire thing.
so i have given up as far as suing them as you cant get any thing back accept the cost of the surgery. no lawyer fees no travel fee etc... GRRRR
ok enough of that now just writing about it again has in raged me once again.
chuck

i am a 43 yr old male. denied L5/S1 disc replacement by unicare insurance. no worker's comp -- only personal health ins policy. i am optimistic to be chosen for active-l disc study beginning in dec.

Denied, Denied, Denied...UHC, PPO two level L4-S1 ADR and/or hybrid. Final decision came from the company's Director of Human Resource. Not a WC.

I agree with Chasswen, just typing this puts me in a BAD MOOD.

I live in Southern California. I was first injured in a student fight, at the high school where I was a teacher. I suffered a second injury lifting a heavy box over another one, also at work. No surgeon on the list Workers' Comp gave me does cervical ADR, so in effect, I have been denied. Dr. Regan (not on my list, I paid to see him and another surgeon out of pocket) recommended a two-level ADR.

Hi all,

Been denied,denied, denied by Blue Crap of Nebraska for a single level Charite.

Had to go fusion route on L4-L5. I am just about three weeks out and I remember that I felt better when I had ADR surgery.

Sue S

Sue,

I find your post a little alarming. Hope you can expand on your "signature" a bit.

What jumps out at me is that you're having a fusion at an adjacent disc level just 2 YEARS post ADR????

Since you had Kineflex..I am thinking it's likely you were a participant in a Kineflex ADR clinical trial.

Did you specifically and medically determine that your L4/5 was healthy before entering the clincal trial on your L5/S1 or did they think your L5/S1 was worse and somehow you still got into the trial when you where really a 2 level candidate before your ADR trial.

Do you understand what I'm getting at? Because the point of ADR is to preserve motion so you don't need another surgery at an adjacent level, especially so soon.

Just raises a red flag! Hope you can shed some light onto your specific circumstances.

LBP,
I am on the Keniflex/Charite study. At the time I really did need a two level. My surgeon and did speak about this and the study was for only one. He put himself out on limb and decieded to replace the worset disc which was L5-S1. The disc was totally discenagraded. We were hoping that L4-L5 would be ok.
About six months after the ADR, L4-L5 started acting up. I have not had any problems with the Keniflex disc. My opinion that this ADR is fantastic and if I could I would love to have another one.

Does this answer your question LBP. I will change my signture.

Sue S

thanks for the clarification because otherwise it seems like a very accelarated wear and tear of an otherwise healthy adjacent level disc...which would be scarey info!

It will be interesting to watch your recovery over time since you have the fusion at 4/5 with ADR at l5/S1. Normally in a "hybrid" situation,it seems preferrable to put the adr at l4/5 and fusion at the less mobile level of L5/S1. Because of your circumstances with the trial restrictions....yours seems to be a little abnormal or at least the opposite of what others have done before when having one hybrid surgery.

would like to hear about your fusion experiences at l4/5.

Hello LBP,
I am new and I am chiming in. I was denied for a two level prodisc L4-S1 by two separate policies, Blue Cross and Blue Shield. I appealed for an IMR and was denied again. I won't give up yet. I paid cash for my surgery. My goal is get so much better that I can prove my surgery was valid. How is your research going?
Phylly

I had Blue Shield HMO insurance and was denied any ADR surgery, but I was indicated for 3 levels. I also asked about seeing Rick Delamarter in Santa Monica, CA, who is only 45 minutes from me, because he is an excellent surgeon performing ADR surgeries and clinical trials, but they would not cover me seeing him, either. My NS (the only one in my area) does not perform ADR surgery. In 3/07 I went to Dr. Bertagnoli and am much better as a result.

I was denied coverage by United Healthcare even after 4 appeals and ultimately payed all expenses out of pocket for a single level ADR in Feb 2006. UHC stated that there is not enough long term research results so they deem it as still an investigational stage device. I reside in Durham, North Carolina. My doctor submitted an official complaint to the North Carolina Insurance commissioner and included all his patients who were denied and their respective insurance companies justifications at that time but with no luck.
Good luck with the list! I was looking for something like this before my surgery.
Take care,
Riley

CIGNA denied 2-level ADR Request Sept 2007
CIGNA denied 2-level ADR 1st Appeal Nov 2007 (? look-up item on the appeal date ?)

Cigna wrote I have one (1) appeal left. I hesitate to believe what Cigna wrote without reading the insurance policy. Cigna saw there was an auto-accident & lawsuit. Surgeons may think symptoms are exaggerated, see "Validity of Self-Reported History in Patients with Back and Neck Pain after Motor-Vehicle Accidents (MVA) , NASS 2007 Annual Mtg. CIGNA's "ADR / TDR Coverage Position" is single-level only. Cigna will not pay for a hybrid surgery, ie.
<UL TYPE=SQUARE>ADR L4/5
Fusion L5/S1[/list]CIGNA will pay for a two-level fusion.

Litigation is a conta-indication for Fusion or ADR, I suggest. My litigation is over. Symptoms are still here. Somehow I thought I must be fabricating pain?? What was I thinking? Oh, right, no fusion because of "long-term outcomes", re-operation rates and adverse events. Is there an alternative, uhh, what's ADR/TDR?

P.S. UCSF, a trial site for Prodisc, was my last surgical evaluation of 4 surgeons. UCSF helped with the request / appeal. UCSF may possibly track the number of ADR denials as an adjunct to the FDA trial, just an impression, no hard data.

Slackwater -- if Cigna's policy covers one level ADR why won't they cover a hybrid?? If you haven't already, you should request all of Cigna's documents, internal rules, guidelines, etc relevant to your appeal for benefits coverage for ADR. you are entitled these documents and there should be language to this effect in your denial letter. however, you need to request them NOW before your appeal window closes. although i was unsuccessful in obtaining coverage, i found these documents very helpful for my final appeal... my carrier had copies of many of the ProDisc studies which compare favorably to fusion so I cited data in the documents United Healthcare was using to deny coverage back at them, stating I believed they had misapplied Plan provisions b/c of such and such data in their documents, FDA approval, nothing in my policy through my employer specifically excluding ADR, etc. Anyway, I hope you have better luck w/your final appeal, esp since they'll allow a single level. i know the process is infuriating to say the least. United would not even approve a single level, but I kept appealing b/c they never denied my claim because I needed 2 levels, they just denied b/c experimental/unproven.
best of luck,
liz

just to clarify.

I am not actively working on some big lawsuit ...researching law firms etc because a long time ago, someone posted research about fed laws precluding bad faith type lawsuits.

I still think it's important to share stories and keep an active list going. In some situations someone might be able to help an individual case and worst case...at least you know you're not alone in getting denails when you wonder how the list of those post ADR surgery continues to grow!

First, thank you for thinking of me. It's appreciated. Good question on "<span class="ev_code_BLUE">Hybrid</span>".

You wrote Hybrid and I suggest(?) you are on the right track and synchronized wth the surgeons posting results of "Hybrid" surgeries. In parallel there are papers published debating which lumbar level should be fused v. ADR.

You mentioned <span class="ev_code_PURPLE">CIGNA's ADR policy</span>, ... paperwork items. Cigna's coverapge position was in my briefcase when I went to see the Orthopaedic surgeon at UCSF last year. The Cigna coverage postion is found here, HERE. No big need to read unless you have Cigna. I see the coverage position is updated since I last read it, but the net results is the same. I will try cut-and-paste below so people stay in no-surprise mode.

===============================================
Coverage Position
Revision Date 12/15/2007

CIGNA HealthCare covers the surgical implantation of a Charité® or ProDisc®-L lumbar
intervertebral disc (IVD) prosthesis for chronic, unremitting, discogenic low back pain and
disability secondary to single-level degenerative disc disease (DDD) as medically necessary in a
skeletally mature patient when ALL of the following criteria are met:
<UL TYPE=SQUARE><LI> The unremitting low back pain and disability described has been refractory to at least six consecutive months of standard medical and surgical management (e.g., exercise, analgesics, physical therapy, spinal education).
<LI> Single-level disc degeneration has been confirmed on complex imaging studies (i.e.,
computerized tomography [CT] scan, magnetic resonance imaging [MRI]).
<LI> The planned implant will be used in the L4-S1 region if Charité or the L3-S1 region if ProDisc®-L.[/list]CIGNA HealthCare does not cover the surgical implantation of any of the following because they are considered experimental, investigational or unproven:
<UL TYPE=SQUARE><LI> A Charité or ProDisc®-L lumbar intervertebral disc prosthesis when any of the following apply:
<LI>> The planned procedure includes the combined use of a prosthesis and spinal fusion.
<LI>> Simultaneous multilevel implantation is planned.
<LI>> The implant will be inserted outside of the L4-S1 region (Charité) or outside of the L3-S1
region (ProDisc®-L).
<LI>> The patient has osteopenia or osteoporosis (T-score < -1.0).
<LI>> The patient has a history of prior lumbar fusion.
<LI>> There is evidence on imaging studies of ANY of the following:
<LI>•• degenerative spondylolisthesis of Grade 2 or greater
<LI>•• infection
<LI>•• multilevel degenerative disc disease
<LI>•• nerve root compression or spinal stenosis
<LI>•• pars interarticularis defect with either spondylolysis or isthmic spondylolisthesis
<LI>•• scoliosis
<LI>•• severe facet joint arthrosis
<LI>•• spinal fracture
<LI>•• tumor
<LI> A lumbar disc prosthesis other than Charité or ProDisc®-L[/list]CIGNA HealthCare does not cover the implantation of cervical intervertebral disc prosthesis (e.g., PRESTIGE™ ST) for any indication because it is considered experimental, investigational or unproven.
======================================


Agree with you, I should get on with the next, Last(?) appeal, just to go through the process again. Delightful. Thank you for reminding me (kicking my rear) on this item.

Net result is I will have pay cash for a 2-level ADR, or hybrid ADR-Fusion. Loss of Reflex, Drug Use Increase, No Exercise Capacity, ... and more loss of physical capability and will lead to other complications / restrictions and will push me into surgery. Waiting too long may force one (me) into fusion because the facets will be further damaged beyond normal aging due to loss in disc height, ... trade-offs.

Slackwater

Above web link led to a blank page where text was deleted. The abstract, not the full article, of Dr. Carragee's article in <span class="ev_code_PURPLE">The Spine Journal, Volume 8, Issue 2, March-April 2008, Pages 311-319</span> is below, <UL TYPE=SQUARE>Validity of self-reported history in patients with acute back or neck pain after motor vehicle accidents[/list]===================================

Well, ..., I know my body ages. Aging means my discs are expected to degenerate (dehydrate) like anyone else's discs and yes I probably had some level of osteophyte growth. However, my foot was not tingling & my legs were not twitching with spasms requiring muscle relaxants and vicodin before the SUV rear-ended me. I may not like to read what all the surgeons have to write, but I want to read it anyway.

Add me on to the list of those denied ADR.
Blue Cross of Ca denied once and then appealed. Yesterday, got notice they upheld the denial, reason, "investigational".
Have qualified for IMR with Dept of Managed Health Care. Who said, "I have not yet begun to fight"?
I will get this surgery at L4/5 paid for.

Kimmers