My suggestion is to contact the Insurance Warrior. Harrison has her website on this forum. She gave me some good ideas for the appeal.
I can tell you insurance companies will argue two things at the minimum to state something is "experimental" or "investigational", although it isn't. Medicare in their CMS? report did not approve disc replacement for patients over 60. Now most patients under medicare are 60 or more but not all. So as I understand it if you are insured under medicare and less than 60 they will cover it.
The second thing they argue is that the FDA requested further studies for the lumbar disc ProDisc and therefore they (the insurance co) consider it investigational/experimental. Now I don't remember if that applies to the Prestige disc but they wanted five years after FDA-approval to approve the disc. So going on that assumption, ProDisc will be viable for them in 2011.
You really have to get at them by finding the evidence they have approved the Prestige and pester them to death. Cervical ADR is proving to be very effective with a high percentage of successful surgeries.
Good luck,
Kimmers
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hurt back lifting, herniated disc at L4/L5. DDD
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