[kimmers]

Insurance companies are not logical.

Although ADR surgery might cost less than fusion surgery, in the short term and the long term, they do not care.
Yes, since I was having an ADR at L4/5 and it was basically almost the same surgery as an ALIF, you would think that if I paid for the ADR, they would pay for the surgery, but NO.

I hate to get on this soap box because it makes me so angry. I was basically told, (and this was from the head of grievances and appeals) that I could have a fusion and not an ADR surgery. Why not the ADR? Because there wasn't FIVE years of post-ADR approval studies on the ProDisc.

Well, I could not wait for five YEARS. I eventually got my ADR surgery but I went through postponements and it was just an incredible fight. I had help from my surgeon's office manager to do appeals. When we presented European and United States studies showing that ProDisc ADR was as good or better than fusion, I got a letter saying that only American studies would be accepted and that was a mute point because ProDisc was approved in 2006 and it was 2007 and that is not five years.

It went on and on.

I can tell you that you have to fight for the surgery and there are some people who didn't have to fight and were approved after one appeal. That is the fickle thing, they will approve one person and turn around and deny the next person. I would ask the insurance people, "How can you not approve me on the basis of there not being enough US long-term studies and then approve so and so??

I knew people in almost the same circumstances as me, same level, same DDD, who were approved.
When I asked, "Why they were approved?", I was told they could not discuss this with me because of HIPPA regulations and each patient's case "was decided on an individual basis."

People on here have suggested googling the insurance warrior because she has some good advice, I did contact her and that was helpful.

My best advice is that you don't take anything for granted and fight the insurance companies with everything you have. You have to be really serious and careful because the insurance companies will just expect you to roll over and follow their decision.

The sooner you push for everything on your first appeal, the better. I would call the insurance company everyday. I didn't do that and that was a mistake. I did call them several times and it was a pain-in-the-neck because it was difficult to get through each time. Also when I got my first denial, I didn't know to ask my surgeon to have a person-to-person conference call with the physican that denied the ADR.

They (the insurance companies) do not tell you what you can do to get approved, you have to find out by yourself and you have to document everything. (I am just speaking about the insurance companies who do not want to approve ADR.)

Good luck,

Kimmers