Quote:
Originally Posted by laid up doc
See my signature below.... I've exhausted my non-surgical options and am looking at surgery options. I'm having allergy testing next week, but per Prodisc's website, a person getting a prodisc "Must not be allergic to cobalt, chromium, molybdenum, polyethylene or titanium". I'm definitely allergic to nickel, and fear being allergic to any of those other things. Am being tested formally next week, patch testing and LTT blood work.
I feel like i'm in a pickle and in for a big fight.... but still trying to figure out what to fight FOR. I'm hoping SOMEONE out there has won an appeal for 1. out of country ADR for device not available here, or 2. fusion for disc pain...
1. Aetna states that they only cover FDA approved single-level ADR. Which is great, for a lot of people... but not for ME. Prodisc is the only disc currently being made in the US. There are still some Charite's out there, but both contain cobalt and chromium. I'm a highly atopic individual... lucky me. There are titanium discs in Europe - particularly the M6L. I spoke w/ Aetna today - they say they aren't in network w/ any international docs, and my policy covers emergency treatment only.
2. Aetna states that they don't cover fusion for discogenic pain. Isn't it great that 2 of my surgeons unequivocally hate lumbar ADR's and suggest fusion. I would love love love to know of a precedent where Aetna has covered fusion when the ADR available here is contra-indicated.
If anyone has any input on these 2 scenarios, please contact me by PM or on this thread. thank you!!!
|
1. Unless your Aetna plan is a fully self administered and funded plan like mine you are probably not going to have much luck having someone high in the chain of command approve an out of the country procedure like the one you are seeking as an option especially if the Prodisc is available in the US even with your pending allergy testing. And while I am no expert on metal allergies but have friends who are immunologist, I wonder if the titanium will also pose any cross sensitivity risks to your nickel allergy. Additionally the M6 has no FDA approval in the US and that is the first thing Aetna will claim in order to avoid paying for the procedure but like you and I already know it is mere politics and Synthes the mfg of the Prodisc has called foul play (patent right infringement) on the keel design that prevents the use of the M6 in the US. You may however be successful in having them overturn their stance (Clinical Policy Bulletin) by having them cover a fusion for discogenic pain if your allergy testing contraindicates the Prodisc L or Charite.
In my personal experience I almost went this extra route when I was initially unable to find a neurosurgeon who was up to date on the modern advancements of ADR as well as performed such surgeries. I had no other choice so I began the "alternate" process by calling a former colleague of mine who currently is now one of like twenty Vice President at our hospital-- coincidentally Vice President of Operations for Ambulatory and Surgical Services at our hospital-- to seek his advice. He is very well spoken, intelligent and easily put me in contact with one of his connections-- an individual within the hospital Human Resources department who was instrumental with most of the policy and underwriting for our Aetna plan. If anything I believe he would have probably made the call to "that higher being" in order to have certain policies overturned in my favor. I have heard of case by case scenarios being overturned despite what certain information Aetna may quote and this was my logic for seeking this "alternative" route. Luckily I was able avoid it all together as I was able to find a great neurosurgeon who was competent and was all in favor of the artificial disc given my history, characteristics and his knowledge of ADR and spine mechanics.
2. Although not comforting to know and perhaps not the easiest most stress free process to undertake is the appeal process. I have been, in my opinion, lucky on winning a few appeals for totally unrelated issues in the past but it was time consuming and stressful. Sometimes to the point that I just wanted to quit and give in.
3. Hopefully your formal allergy testing confirms that you are a candidate for the Prodisc or M6-- whichever route you decide on. I know that you still have concerns about ADR vs. fusion from reading your other posts. But I hope that you can clear you mind and are able to make a clear and concise decision because no one deserves to live in pain. I know it is difficult because you have many factor or variables such as your pending lawsuit which limits your choice(s) and if you are anything like me very analytical and critical it is a tough decision to make. I know that it was a difficult road for me and not an easy decision but I must tell you that I am happy to have done the Prodisc L. I-- like you-- wish that the M6 was another option available in the US but unfortunately that is the nature of the beast and I really didn't want to act selfish and spend our savings to travel abroad to have what is probably considered a more advanced artificial disc placed in me. I also still ponder what the future will hold for me and my Prodisc/spine in the next 2, 5, 10, 20 years but I prefer to take it one day at a time and enjoy my children, my life and a world free of pain!
Please keep all of us updated as to the results of your allergy testing and your decision. Your case is very unique. Good Luck!!!!!!