[RedTx]

Hello everyone,

I am trying to gather some information to help our decision making going forward. My 42 yo husband has chronic debilitating pain in his neck, shoulder, upper back that is non-specific. We have seen countless doctors and are now told it’s discogenic pain. One doctor suggested that before we go through with the cervical discogram, we should try and determine if insurance would pay for the surgery. The discogram is not covered ($3500) by any carrier, but we specifically have Aetna. We have reviewed their policies bulletin and struggle to see if we qualify for ADR surgery. No real radiculopathy symptoms. Some mild and moderate herniations and some annular tearing, but no clear neural or cord impingement (c5-6 has the biggest herniation with a tear).

Question: What’s the likelihood of ANY insurance carrier paying surgery for discogenic pain that doesn’t really qualify in the normal impingement/radiculopathy sense? We may switch to BCBX TX in January and their policy bulletin is similar in needing to meet “all requirements”. Also, how can we really apply for the surgery if they won’t cover the discogram? Can we submit the results for a test they don’t even believe in? What records are included when a submission is made? Can we guide/help the submission process?

For simplistic purposes, assume this would be a single level ADR. I think the discogenic pain diagnosis is going to be difficult enough and if it’s multilevel we are totally hosed.

Please offer your experience/guidance based on your own or someone else’s report regarding what kind of things we should expect for insurance coverage/denial. Also, if you have any opinions on whether we would be better off with Aetna vs. BCBS TX, please let us know. We could save some $$$ switching to BCBS but paying for surgery out of pocket sounds ridiculous.

Thank you!