Don,

It sounds like you have a PPO which usually offers the least amount of benefits. I did a cost analysis of fusion versus adr and the difference was $60,000 more for the fusion. The company did not care about the price difference. I was told that all the money is pooled into a fund and if the fund runs out that year they have "back up policy" to cover the additional insurance needed. Most companies will not pay directly out of another account. It can create a "precedence" for others to request "special services"

It is a HUGE problem in the US. I think the only way this will get fixed is if everyone became insurance savy and said, enough is enough. Most people, myself included never think about my coverage until I needed it.

The insurance company is the adminstrator/paper pusher for the policy so there is no leverage with the insurance company. At the end of the day, human resource will determine if you are "eligble" for the procedure. Since most self insured companies buy the cheapest policy they can all "experimental" surgery is denied.

I am glad you voiced your concerns and hope that you have enough clout with your company that they will go out on a limb and approve your adr.