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Old 08-28-2011, 11:29 PM
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jss jss is offline
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Scott,

Condolences on your condition and dilemma; but welcome!

You know, effective lumbar ADR has been around for over 20 years. Some insurance companies today will deny fusion because ADR has sufficiently better outcomes. It's enough to make you crazy.

BCBS is a conglomeration of insurance companies. So while BCBS-TX and BCBS-Michigan will cover ADR, that doesn't mean that BCBS-Anthem will cover ADR. Yes, many of the BCBS constituent companies have paid for ADR. Which BCBS do you have?

BCBS-TX would not cover my double ADR, though they approved me for a single level.

Quote:
Originally Posted by semathes View Post
1. If I pay myself and have any trouble either now or in the future, I assume BCBS will never cover any remedial work and I could lose the house as well as the college fund.
I don't know the answer to this one, but would tend to doubt that BCBS would not cover an ADR revision. More and more insurance companies are covering ADR, and it follows to reason that your company might cover ADR by the time, God forbid, you need a revision.

Quote:
Originally Posted by semathes View Post
3. Has BCBS ever approved anyone? If so on what basis?
BCBS is a conglomeration of insurance companies. So while BCBS-TX and BCBS-Michigan will cover ADR, that doesn't mean that BCBS-Anthem will cover ADR. Yes, many of the BCBS constituent companies have paid for ADR. Which BCBS do you have?

BCBS-TX would not cover my double ADR, though they approved me for a single level.

Quote:
Originally Posted by semathes View Post
4. Are there any studies I can use against BCBS's experimental basis of denial? Can the long history of work in Europe be used?
I can provide you with my last appeal to BCBS-TX. It includes 91 pages of clinical data from single and double blind studies amounting to over 800 years worth of clinical data that prove the safety and effectiveness of multilevel ADR. Though the appeal is iron-clad, BCBS did not reimburse me. If you want my failed appeal, PM me and I'll tell you where you can download it.

Quote:
Originally Posted by semathes View Post
5. What are the best reasons to have ADR as opposed to a fuse?
Per Dr Alan Hilibrand's landmark 1999 study, one cervical fusion results in a 25% chance that you'll require a 2nd one within 10 years. It is generally accepted that one fusion, cervical or lumbar, will result in another. Though ADR has yet to develop into a silver bullet for spinal problems, such a pattern has not been shown with ADR.

While there are very good reasons to select ADR over fusion, in many cases there are very good reasons to select fusion over ADR.

Quote:
Originally Posted by semathes View Post
6. Does anyone have experience involving the manufacture (Pro-Disk) in the appeal process?
I don't have this experience but can tell you that some manufacturers will provide you with a sample insurance appeal upon request. I've seen a few of these and don't know if Synthes provides that sample appeal.

If you're a good candidate for ADR, I'd strongly recommend that you vigorously pursue your insurance company for coverage. In my case I had to have surgery immediately and didn't have the time required to battle BCBS-TX before surgery. As a result, they had absolutely no incentive to reimburse me after the surgery. As my surgery, in Barcelona, cost about half of what it would have cost in the US, I feel that I would have had a good chance of getting coverage had I had the luxury of time before surgery.

Good luck, Jeff
__________________
C4/5 - ACDF in 2000
C5/6 - ACDF in 2002
C3/4 & C6/7 - M6 ADR, Nov 2009, Barcelona
Conceded defeat to a manifestly disingenuous BCBS-TX in my quest for reimbursement, Jan 2011
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