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Old 07-11-2009, 06:47 PM
Deborah Deborah is offline
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Join Date: Sep 2008
Posts: 78
Default Medicare paid hybrid

We have Medicare primary and a standard 'medigap' add-on insurance to pick up the difference (between % between what Medicare approves and total amount Medicare has approved). Hub is 42 years old and meets criteria for ADR; we discussed at length 2 level ADR v. hybrid, but decided hybrid made sense (jury still out on if there is a definite preferred for those 2 levels done together, in my opinion).

Hub had hybrid surgery March 3 - L4/L5 Prodisc and L5/S1 fusion. It was discussed at length with Medicare prior to surgery (Nov 12 - Jan 22) with myself, the doctor, CMS and the doctor/contractor for CMS. The doctor worked very hard proving it was necessary, but did win a tentative 'we would cover if done as described' decision.

We all still held our breath - the total bill was well into 6 figures. This week we got notification Medicare had paid, and the add-on paid the difference as required by law/contract (the amount paid was based on Medicare contract, which was the amount the hospital billed for all services).

It would have been impossible to do without the coverage, unless we sold our home. As it is, we cashed in most of savings to cover incidentals along the way. Surgery took place March 3, and hub is off meds (other than occasional muscle relaxant) for 2 weeks now. Prior to surgery he was on 60mg oxycontin 3xday plus break throughs; after surgery it was 20 mg methadone 2xday, within a week 10mg 2xday (plus dilaudid break throughs) and taper from there.

He's still quite weak and is just about to get into PT (he honestly hasn't been able to go regularly yet). He is able to putter around the house a bit most days and he's 'all there' mentally. We can have friends visit again, and life feels so much more normal, with his strength and abilities improving every day.

2 years prior to surgery he had hit the low of being basically bedridden - accident causing injury was in 2001 and he'd tried it all from minor surgeries to electro stim implant 2x, all kinds of meds, all kinds of PT. Tests in Sept 2008 (CT, MRI and discogram) all pointed to the problem being L4/L5 and L5/S1 with the rest looking healthy. All of this I would assume contributed to the approval. I have no doubt the results would be the same with someone of any age ... the age cutoff seems ridiculous.

I hope the information can help someone else!
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Deborah

C3-5 fused 2001
Hub: C3/4 fused 2001
Hub: TDR Prodisc L4/5, Fusion L5/S1 on 3/3/2009
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