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  #1  
Old 07-26-2010, 08:39 PM
Abarco Abarco is offline
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Join Date: Jul 2010
Posts: 9
Default Triwest cervical ADR denied

Hi everyone,

I was wondering if anyone had any help, guidance, or approvals for ADR from Tricare? I received my denial letter on Friday and sent in the below letter for reconsideration

26 July 2010
TriWest Health Care Alliance
Reconsideration Department
PO BOX 86508
Phoenix, AZ 85080


To Whom it May Concern:

I am writing to request a formal appeal of the rejected proposed
treatment, cervical disc arthroplasty, for the following diagnosis:
* Cervical Disc Degeneration
* Chronic pain to neck and to right scapular region
* Chronic Muscle spasms to neck and to right scapular region
* Nerve Palsy to right upper shoulder and arm
* Cervical Radiculopathy
* Spondyloarthropaty of cervical spine
* Loss of normal lordotic curvatrure of the cervical spine
* Mild disc desiccation
* Headaches
All of my above listed medical diagnosis are documented with associated
numerous tests that I have been put through since approximately 2007.
Sadly, I have attempted and failed numerous rounds of conservative
treatment only to live in constant pain and always scared and guarded to
not have an acute spasm which feels like I have been struck by lightning
in the back of my neck. This is also affecting my career because of the
numerous medications and vigorous expectations that are demanded by my
profession. I can no longer work as an emergency-trauma Registered
Nurse Specialist. I am currently in graduate school for Acute Care
Nurse Practitioner but with my chronic neck problems this could shatter
my dream, as well. At my age a fusion would literally put me on the
"bench" forever. I have three young children that I would love to
conquer adventures with. With a fusion there would be serious
limitations. I have tried soft c-collars, trigger point injections,
Chinese acupressure, Chinese acupuncture, cupping, tens-unit, moist
heat, cold therapy, cervical pillows, tempur-pedic bed, physical
therapy, professional massage, chiropractic adjustments, freezing and
stretching with ethyl chloride, prednisone, NSAIDS, narcotics, lyrica,
neurontin, muscle relaxers, the Felix trigger point board, cervical
epidural injections, facet injections and ultra sound therapy. I have
literally spent thousands of dollars and have exhausted every possible
remedy to relieve this horrible condition so that I can start living my
life like I used to. Dr. Briggs, my neurosurgeon from the Springfield
Neurological and Spine Institute, Dr. M. Akhtar Choudhary (my
neurologist) and I have all agreed that the cervical disc arthroplasty
is the most appropriate treatment for my condition and that I DO meet
criteria for disc arthroplasty and should undergo this surgical
procedure. Please find the attached documentation that may be helpful
in your
reconsideration of the pre-authorization claim for benefits and payments
in which Tri-Care does cover for all Active Duty Soldiers, but is sadly
denying their dependants of this medical necessity:
* A copy of "not approved" letter
* Medical Justifications for cervical disc arthroplasty
* Clinical literature on disc arthroplasty
* A letter from my doctor
* Cost benefit analysis reports
* FDA approval letter for the prestige ADR

Thank you for your consideration of this much needed coverage . If there
are any questions please contact me at 573-847-8246

Angela M. Barco RN, BSN

I thank you in advance of guidance as to what else I can do? I am so tired of suffering....
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  #2  
Old 07-27-2010, 07:01 PM
sahuaro sahuaro is offline
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Join Date: May 2005
Posts: 455
Default

There was a letter from some governmental agency to insurance companies indicating that if they were offering federal insurance, they could not second-guess the FDA by denying FDA-approved procedures, devices. etc.
I assume that would be relevant for your case. I'm sorry for being so vague but it's been a while since I was where you are (but lost my appeal to Health Net). I would guess that this letter was posted on this board 2-3 years ago.
I will try to locate my copy, but you may want to do a search here.

Wishing you all good luck.
__________________
2001 MVA; C5-C6 disk extruded
ongoing physical therapy, exercise and massage
ESI's, oral prednisone, trigger point injections
foraminal and central stenosis C5/C6 and c6/C7
2007 EMG/nerve conduction shows pattern of chronic radiculopathy
January, 2008: Prestige ST Artificial Disk Replacement, C5/6
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  #3  
Old 07-27-2010, 08:45 PM
Abarco Abarco is offline
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Join Date: Jul 2010
Posts: 9
Default Triwest VS Federal BCBS

Thanks for the reply.....A good friend of mine is actually the chief of referral Management for Triwest... LOL..... The ADR procedure code is actually on their DO NOT PAY list, FDA approved or NOT...
Although I have had TriWest for over 10 years, I was given the advice that since I am a federal employee and open season is in October to just keep taking all my meds :-( and enroll in Federeal BC BS and on Jan 1st I am eligible for care and have the Neuro Surgeon send the Pre- Auth to them......

Or stay with Triwest and get a fusion because that IS a covered procedure....

So I guess I need to start reading about the different BCBS plans so in October I am ready to pick one and hope for the best.....YIKES


Is your insurance company willing to pay for the fusion?
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  #4  
Old 07-27-2010, 09:51 PM
sahuaro sahuaro is offline
Senior Member
 
Join Date: May 2005
Posts: 455
Default

How wonderful that you have an alternative!

I assume Health Net would have paid for fusion--which would have been 2-level and probably more expensive both for surgery and hospital stay. However, fortunately, I was able to pay out-of-pocket for ADR and I am very pleased with the outcome!
__________________
2001 MVA; C5-C6 disk extruded
ongoing physical therapy, exercise and massage
ESI's, oral prednisone, trigger point injections
foraminal and central stenosis C5/C6 and c6/C7
2007 EMG/nerve conduction shows pattern of chronic radiculopathy
January, 2008: Prestige ST Artificial Disk Replacement, C5/6
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  #5  
Old 08-25-2010, 09:48 PM
Abarco Abarco is offline
Junior Member
 
Join Date: Jul 2010
Posts: 9
Default Tricare Reconsideration dept still Denied

Received my reconsideration but still denied because it is not a covered benefit...I was actually surprised but to no avail still denied, when I called they said fusion is covered....After feeling sorry for myself, I reproached the entire situation.. Military Treatment Facilities do not bill Tricare so I contacted Walter Reed Hospital and received great news, I was correct!!! I federal expressed my radiological images and medical records, they were reviewed by the neurosurgical department..Today I received a phone call that I was accepted and scheduled for a C5-C5 ADR on September 16... Now the chaos begins..flights, hotels, childcare for my kiddos , leave !!! I am so excited, relieved and now nervous!!!! So now I get to read post about after surgical procedure and what to expect woo-hoo......Angie
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  #6  
Old 08-25-2010, 11:40 PM
sahuaro sahuaro is offline
Senior Member
 
Join Date: May 2005
Posts: 455
Default

That is so terrific!
But, now I'm confused: who will be paying for the surgery?
__________________
2001 MVA; C5-C6 disk extruded
ongoing physical therapy, exercise and massage
ESI's, oral prednisone, trigger point injections
foraminal and central stenosis C5/C6 and c6/C7
2007 EMG/nerve conduction shows pattern of chronic radiculopathy
January, 2008: Prestige ST Artificial Disk Replacement, C5/6
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  #7  
Old 09-27-2010, 03:02 AM
Abarco Abarco is offline
Junior Member
 
Join Date: Jul 2010
Posts: 9
Talking

Sorry for the delay, I received my prestige TDR C6-C7 at Walter Reed on September 16th, 2010, they were wonderful... I think I am doing really well, have great mobility as far as I will push anyway.. My voice is no where near normal but slowly its coming back....I was able to eat 3 hours after surgery without a problem but kinda weird because I do still choke a lil on fluids but not food.... The strength to my right arm vastly increased post op (I could actually twist off a bottle top) right after....I cannot be honest on my pain levels because my doctors know I am a lil on the wimpy side and have a huge aversion to pain after suffering for so long..... so the most pain I get are some very mild headaches and stiffness but I must be honest because I DO take my medications so I have not yet tested the "weaning" off..My docs have me on Robaxin, Percocet, Motrin, Cymbalta, and if I do get any severe muscle spasms I have Valium on hand (which I have had to take 3-4 times)....So I think I am doing really well.....I dont know if its common but I am fearful of self weaning because my pain is under control and in the past if I let it go the pain is pretty much impossible to get back under control with the daily routine meds and I hate having fight to get my pain back under control, if this makes sense to anyone? Any advice is welcome :-) Thanks...SO FAR AN AWESOME OUTCOME!!!!!
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  #8  
Old 09-27-2010, 07:12 PM
Tatonka_usn's Avatar
Tatonka_usn Tatonka_usn is offline
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Join Date: May 2009
Posts: 75
Default Who did your surgery

Abarco,

Really glad to hear that TRICARE finally relented and covered your cervical TDR. Had a couple quick questions I was hoping you might be able to answer (at your convenience):
- What is your status relative to the military? Are you active duty, a dependent, or a retiree? The reason I ask is that I'm a veteran who recently left active duty after 13+ years, and TRICARE will no longer touch me (ie I have to deal with the VA for my service-related back issues).
- Who did your procedure at WRAMC? Dr. Michael Rosner did my L5-S1 discectomy back in July 2007, and used to use the Charite for TDR. While I last met with him (this past May/June), he advised that he no longer performs TDR, as he has lost faith in the practice (believing TDR is not effective for mechanical back pain). If he is no longer doing them (as head of Neurosurgery) I'm curious who is still performing TDR there?
- How did you ultimately convince TRICARE to relent and authorize the procedure? From my experience, they drag their feet at any/every opportunity, so you must have some sort of effective strategy/approach to overcome this.

Hope you have a smooth recovery, and wish you the best for continued improvement!

Best regards!
Alan

P.S. Feel free to PM me with any/all information if you prefer....
__________________
4/07:LBP + radiculopathy=severe L5-S1 herniation , 7/07:Micro-D, 08-09:Reherniation, 09-17: periodic residual symptoms (conservative modalities to maintain "stability" = prolotherapy, ESI/nerve blocks/facet injections, chiro, massage, phys ther), 7/17 pain in neck/right shoulder radiating into hand (no trauma involved), 7-10/17 Conservative treatment to date include physical therapy/dry-needling/facet-injections (C4/5 to C6/7). Researching surgical options should progression continue.
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