Anyone get ADR covered by BC/BS
 

Has anyone successful got coverage from Blue Cross/ Blue Shield? If so can you please tell me your name , doctor, procedure and date of coverage.

I am preparing an appeal for a 2 level ADR in my cervical spine. Of course , they have denied coverage deeming the surgery; "investigation" and "unsafe"

Thank you so much. You can respond to this thread or send me an email privately.

We have to stick together and not take no for an answer!

Revised January 15, 2013
BCBSF Medical Policies (Medical Coverage Guidelines)

Blue Cross Blue Shield Coverage Position above.

See your provider and find the "Coverage Position". It appears to be 1 level in Florida.

The question to ask is if the proposed surgeon in BCBS has done the training and how many ADR/TDR operations have been performed, post-surgery NDI at 6 and 12 months for how many patients.

Check out this thread.
 

http://www.adrsupport.org/forums/f43...dvocate-11305/

The advocates are a great help. I did not need it though. My surgeon fought the fights for me. All I had to do is go through the tests requested.

I called an advocacy and they said they couldn't help me. They said doing a cervical 2-level ADR was off label. That two level hasn't been FDA approved. What kind of baloney is that ? How long has Dr. Clavel been doing more than 1 level? The FDA in America act like they are protecting the consumer and patient but what their really doing is hurting us and leaving us out in the cold in pain:mad: . They really seem to protect the insurance companies ..

Running

I have BCBS & I applied for reimbursement with Worldwide Blue, the international rider on my policy. It has been approx. 6 - 8 weeks & so far the only thing I have heard is that "it is under review" and they gave me a claim number. Will keep you posted.

I had two level ADR with Dr. Clavel in Oct. 2012. I think everyone should file a claim with their insurance company & fight for coverage. I may not get reimbursed, but I am going to battle! :D

Soon the mobi- C will be approved for two level cervical ADR in US. The FDA estimates late summer 2013 for full approval. This may help with insurance appeals!

I too have BCBS and filed a claim recently. I doubt anything will come of it, but if it makes the insurance people take a second look at adr vs. Fusion then it will be worth it.

I have BCBS, Ohio, and they approved the MRI, follow up, the VA paid for my L2-L3 discectomy, but I believe it is failing, this happened two days before Thanksgiving, and I had the L2-3 done on 3/29.

I talked to the Dr, and we agreed to a 3 level, replaced the damaged one, l2-l3, then replace the two lowest, l4-5 and L5-S1, that is the worst one, I have severe stenosis, the lower two are almost fusing, I will see the results of the contrast MRI and see what is going on for sure,

I will let people know what BCBS does, I am sure they will fight this.

Jerry

Jerry,

I have BC /BS. Going from my experience they will pay for ONE and ONE only.
I went through first, second and external appeals. My surgeon put in for two. They approved one and the one that was the better of the two. What morans.

Even though they only paid for one of mine maybe they'll pay for yours. There's always hope. I had a cervical compression and severe stenosis with three nerve roots compressed. I went through all testing and results were all positive . BC/BS ignored my testing results or didn't read my results and I fought them for a year. I am considering suing them for damages because I have permanent nerve damage in my hands.

My advice to you; don't give up, fight them like h--- kicking and screaming for your life. Don't take no for an answer or listen to any naysayers. They have to start paying! Good luck keep me posted!

Running,

I had a discectomy, at the L2-3 level already, it helped with the pressure on the back, at the site, but these operations need to be resolved in a few days, not weeks or even months(I have numbness in the leg, sensation, lateral femoral, this is a result of 'waiting'), it took 4 months to get that one, and now I am looking at the L5-S1, L4-5, and the L2-3.

There are cases where the whole cervical neck was done, something like 6 or 7 levels.

Disc Replacement Surgery cost and details, Artificial disc replacement surgery.

This has the costs, two level, including flight and aftercare is about $40,000 US.

http://www.germanspinespecialists.com/press.html is another one in Germany.

Both of have done multi-level with the M6.
(Spinal Kinetics)

By the time that the US Insurance Company fights this and pays for optional treatments, they will spend more than twice this.

Silly.

With this technology, developed by NeuroSurgeons here in the USA, California, really has to make one wonder, why not approve this for the states.


I had follow up MRI and XRays this week, the first actually, and will see the DR again on Monday the 8th.

One blow out is enough, I cannot afford another back problem like that, I have been on Meds for EIGHT months, this is ridiculous.

Going for ALL 3.

Be done with it.

More Later.

Happy 4th.


Jerry

Jerry,

I know this is all nonsensical. US insurance should just pay up! They ONLY paid 1/3 of my total bill so why the big tantrum! ?

My right foot and big toe are very numb and painful . I have a nerve root blockage at L5. i don't know when I am going to get that fixed as I am still on the mend from my last ADR surgery. I am a slow healer. It seems as most men on this board heal quickly!

Good luck to you . Keep me posted!:clap:

Tammi

Tammi,

Sorry to hear about the foot and the big toe.

I have residual as well, most of the sensation in the right upper leg is gone.

The pressure is off the immediate part in the back, from the L2-L3, but there is still pain radiating from this area, as well as the 4-5 and 5-1 area in my back and radiates down and out.

(People do not understand this, I ask them, have you had a very sharp pain from a splinter, in your finger, now put a half dozen in your back, and it does not go away)

It hurts to sit, (have a ball chair at home, and a modified ergo chair at work) I went out to eat, and did something, sitting in a chair, and spent several hours on Sunday on my back.

This is what I am trying to prevent, an ounce of prevention is better than a pound of cure.

Just pay for the ADR.


I will have some testing, guess they hit the areas in the back and try to indicate where the pain is coming from, as if I don't know.

Not sure about healing rates, some people heal very quickly.

Jerry

Jerry,

I had two level ADR, m6 disc done in Barcelona, oct. 24, 2012. BCBS paid 60%. I do not know why they paid, but they did. I know many others say that BCBS will not pay for a 2 level ADR, especially for a device that is considered experimental in the US. However, the procedure IS NOT experimental in Europe where I had the surgery performed, which we pointed out to BCBS when we filed the claim. Also, Hospital Quirón is on the approved list on my BCBS rider.

Good luck, I hope you get them to cover your procedure. I think we all need to push insurance companies into accepting this procedure works & in the long run saves money and helps people feel better.v we also need to push the FDA to approve the M6.

Two Level
 

You said you had two level, what levels, and if they are not adjacent is this considered two level, meaning, adjoining.

I really need three, if I am going to do this right.

Have the damaged disc, L2-L3 done at the same time as L4-L5 and L5-S1.

L2-L3, has to be done from the side, or there is a different procedure for that level.

The 27th, I will have another test, not discogram, but electrical stimulus, I guess it hurts, but not like the discogram.

This is really sad, that the FDA is dragging it's feet, there is no reason they would not allow this to move forward, so people can move on with their lives.

BCBS Ohio, is one of the worst, and I have talked to several people, they are going to be dropped.

Most likely, I will drop them next year.

Will post the results of the tests later.

Thank you for sharing your information.

Jerry

Jerry

I had two levels. C5-6 & 6-7 there was some question about 3-4 and I may have to consider that in the future, but have to symptoms and hold high hope that I never need to. BCNS paid 60%.
Best of luck, hope you get them to pay.

Update.
 

2 confused and Tammi,

Just had another consult with an interventional pain Dr.
Have to jump through the ropes.

He will do nerve blocks on the L2-3, L4-5 and L5-S1 levels on the right side in about a week, then after awhile, another couple of weeks, do the left side, same levels, then I have to endure the discogram.

This will happen in the middle of September, why not just do the discogram, get it over with and move on.

This is truly insurance hell, I also have the option of getting some help from the VA, so I am going to use both of them, not sure how this will work, but fusing, rods and plates are OBSOLETE, as long as they have the advances they have now.

The M6 seems to be the best, from what I have read.

If they do not allow a two level, (I am not sure I need an ADR at L4-5, but for sure at L5-S1), and the damaged disc at L2-3.

So this would be a two level but not at adjoining discs.

In the meantime, I take some Codone, which makes me sick sometimes and my stomach sore.

Not sure what else to say, just keep banging away at this insurance (I don't see how BCBS stays in business?).

All for Now,

Jerry

Update
 

Sent the Information to German Spine Specialists, and they came back with the three level, L2-3, (Nuvasive-Lateral) and the L45 and L5S1, I have submitted this on 10/23 2013, no word so far.

I do have BCBS, and Hoping the VA will go along as well, they (VA) are part of the USA medical system, so most likely, they along with the private insurance will say this is investigational.

The M6L is NOT investigational in Europe, and at least one Dr, Bierstedt, has done over a 1,000 of these procedures, and the outcome many years later is good to Excellent.

There is NO reason the USA (FDA) should not approve this medical device, NONE.

Jerry

By the time the U.S. let's us have the M6, it will be the M7! :laugh:

So a 3-level...are all levels with a Nuvasive? I'm not that familiar w/the lumbar procedures. Sounds fascinating-tell us more about if you don't mind.

Nuvasive
 

Jen,
They use some neuro stimulation, if I remember reading this right, so they can tell where the nerves are, that come from the back, toward the front, along the ribs, they can see where these are, and make an incision, between them, off to the side, laterally, just in front of the ribs, about 4 or 5 inches above the belly button, they dont cut anymore, from what I have read, they separate, sort of like tear, the muscle, it heals better that way, and then use the hands to move the organs, much better, and less destructive, the lower levels, they just come in the front.

Nuvasive is described on the German Spine Specialists website.

Your right, once they approve this in the USA, it will be the M7, or 8, silly.

Go to that site, do searches, there is a lot of information available.

Jerry