Hi
I have been evaluated by Dr Blumenthal at TBI and he recommded a 2 level ADR for me at L4/L5 and L5/S1. After being told by 2 customer service reps at our insurance company that this procedure was covered under our plan, I have had pre authorization denied by the physician at the case management level of the insurance company. I am working with Benefits at my husbands company since we are self insured and do have a little more control over covered benefits than some do.
They have advised me to hold off on the appeal but to gather all info I can on why an appeal should be granted.
I am looking for others who have had ADR here in the US and have had their surgery covered by private insurance.
I have found the web page with AEtnas policy and the page from Stenum stating the BC/BS and the federal employees program covers this at least in Germany.
Any help in this matter would be appreciated.
Also if you have info that would help with the appeal please feel free to share. I need all the help I can get at this time.
I am a massage therapist and am unable to work much at all now. This is one reason I wont even consider fusion at this point and time. I am terribly afraid that if I have a fusion I will not get the flexibility back I need to continue in my career.
I also have children and 9 dogs at home so its impossible for me to even think about going to Europe at this time even if I had the financial resources to do so which I dont
Thanks in advance for any help you can give

Hi Kim,
I live in australia, so i guess my input will not mean much to you.
I have had the same diagnosis as you. Discogram with tears at L5/S1 and L4/L5. There is also some mild arthritis in the facet joint at L5/S1. He has given me the option to have a fusion at L5/S1 or a 2 level ADR. He does not know how much the facet joint is involved in the pain though. It is an extremely difficult decision to make, but the fusion can be done afterwards, although I beleive this is a lot more dangerous second time round.
Anyway my insurance company will cover the bulk of the costs, I woil pay the shortfall which is a few thousand dollars. The total cost is between $20,000 and $25,000 aussie dollars. I can't find many people who have had this done here to compare surgeons. My surgeon has performed many spinal procedures but only 35 ADR operations. It doesn't sound a lot to me. anyway I hope you resolve your problem, it is nice to see someone with very similar problems who has been through the same procedures except in another country. Good luck.

I filed a successful 150 page appeal with BC/BS. Email me and I can share some of the information, like table of contents, studies, etc.

Kim

I successfully appealed to the benefits committee at my work (my employer's health plan is a self-retained plan like yours)......here are some things that helped:

1. i have been employed here 15 years and the company feels its a high likelihood that i will be here for at least another 5 years (ie, my future healthcare costs will be theres).

2. I showed them how a fusion (the alternative) would cost just as much in the short term (if not a little more), but by the time you add the additional follow on costs (ie, more drugs and care) plus the way more loss of time from work, ADR is actually cheaper than fusion!

3. I showed them some study data and european data demonstrating ADR's level of success.

Granted in one meeting!

email me at eliu@san.rr.com if you wish to get more details. if you give me a phone number, I would be happy to call you to discuss.

Good luck.

This too probably won't help but Empire BC/BS of Greater NY authorized a two-level for me (now called Empire Health Choice). Unfortunately, it's state by state.

Best of luck, Allan