[colorado babe]

Here are some of the articles that I used in my third appeal from Tricare to an outside agency Kepro that overturned Tricare:

1. Comparison of artificial total disc replacement versus fusion for lumbar degenerative disc disease: a meta-analysis of randomized controlled trials
2. Disc replacement may offer advantages in cost and outcomes over spinal fusion | Orthopedics
3. Cervical artificial disc replacement versus fusion in the cervical spine: a systematic review comparing multilevel versus single-level surgery
4. http://www.adrsupport.org/forums/f43...pay-adr-12341/
Most importantly, please include a letter from your congressman asking to reconsider the findings for the patient and also an office note from your surgeon noting your symptoms when they started and their conclusion/diagnosis, etc. Include a letter that you have written (See below)


KePro
Attn: Reconsideration & Appeals
777 East Park Drive
Harrisburg, PA 17111

August 7, 2014

To Whom It May Concern:

This letter is written to request for a second level reconsideration to the TQMC for a two level cervical and lumbar total disc replacement. For the past 16 years I have been suffering from Degenerative Disc Disease, severe headaches, pain in my neck, shoulders, upper and lower back, numbness in my arms, legs, spasms in my legs, feet and hands and severe sciatica. The degenerative disc disease goes back to 1998 when I was serving in the USAF at Peterson Air Force Base. My symptoms have progressed through the years to the point that I can no longer endure the pain anymore and am suffering from severe depression due to the chronic pain

I have tried to avoid surgery by utilizing traditional western and eastern medical means. Nothing has brought me relief. I was given an upper lumbar steroid injection that caused a severe allergic reaction that put me on FMLA and Short Term Disability on March 5, 2014.

There has been no improvement in my cervical and lumbar spine even though I regularly follow-up with my Primary Care doctors at the VA and through Tricare Providers. Through the years, I have received care with pain management doctors, a Rheumatologist, Physical Therapists and within the past 5 months I have been seen by a Psychologist for severe depression, and two surgeons for consultations. One surgeon that I consulted with (Dr. Chad Prusmack) in May, suggested another upper lumbar injection or a discectomy or fusion. Since I already received an injection on January 31, 2014 that caused havoc in my body I did not consent to this. Dr. Prusmack also discussed fusion, discectomy and a couple other procedures be he couldn’t guarantee that the symptoms I am experiencing would dissipate.

On June 19, 2014 I went to see an Orthopedic Surgeon (Dr. Kenneth Pettine) who came highly recommended and he was on the Tricare Provider list. When I went to my appointment I was immediately impressed with Dr. Pettine’s thoroughness and professionalism. At the appointment he and his staff informed me that I was not a candidate for stem cell procedure for the Degenerative Disc Disease after reviewing my past MRI’s and the x-rays. However, he did inform me that he could perform a two-level cervical and lumbar total disc replacement by using the ProDisc-L which was determined on August 14, 2006 to be safe and effective and approved for use in the United States, under the Federal Food, Drug and Cosmetic Act.. He informed me that trials conducted over the last five years have shown significant advantages of an artificial disc over a fusion (see letter from Dr. Pettine attached). I knew immediately after my three hour appointment with him and his staff that this was the procedure that I felt was best for me and for my body and I wanted him to perform this surgery after spending hours on the internet researching Artificial Disc Replacement vs Fusions.

On July 2, 2014 Dr. Pettine’s office sent the order to United Health Care which is the contractor for Tricare (my insurance provider) for approval to perform the surgery. Tricare denied the procedure and stated it was experimental. I submitted an appeal and was notified by Tricare on July 29th via phone call and letter on August 4 that they had denied the request again because they can only approve one level and not multiple levels on the cervical and that the lumbar code was on the government no pay list.

During the last few days, I have done further research on the internet that indicates that disc replacement may offer advantages in cost and outcomes over a spinal fusion (See Attachment 1) and that total disc replacement has been proved to show significant safety and efficiency comparable to lumbar fusion (See Attachment 2) and also (See Attachment 3) the literature suggests that outcomes are at least similar for multi-level cervical artificial disc Replacement (CADR) and Artificial Cervical Discectomy and Fusion.

Therefore, I am requesting that KePro to please consider and approve Dr. Pettine’s request to perform a multi-level Artificial Disc Replacement on my cervical spine and a single level on the Lumbar Spine.

I am attaching copies of extracts that I pulled from the internet as well as a letter of recommendation from Dr. Pettine. If you should have any questions or concerns, please feel free to contact me at xxx-xxx-xxx. Thank you for your time and consideration. I look forward to hearing back from you.

Sincerely,

XXXXXXX