ADR and Insurance Coverage

[Laura C]

Hello Everyone!

I have been reading many of the posts. How many of you have had your insurance cover ADR? Anyone with Blue Cross? I am starting the appeal process but I don't feel too optimistic about it. I am a patient of Dr. John Regan in Los Angeles. I have a missing facet joint at L5-S1. Collapsed disc at L4-5 and L3-4 is on it's way. The 4-5 space is now bone on bone. Severe stenosis on left side and mod. stenosis on right side. Having discogram and testing the facet joint tomorrow. Can anyone tell me what this test is like (painful?) He is recommending ADR at the 2 top levels and possible fusion at the area where the facet joint is missing (if they find that it is causing pain). I have been in pain for a long time - taking meds round the clock, 2 epidural shots, life altered significantly. 45 yrs. old - in pretty good shape otherwise, gymnast for many years, no trauma. DDD is quite advanced for my age. Anyone have any comments or info on any of the above. I can sympathize with all of you on this forum... thanks.

[Justin]

Hi Laura,

Welcome!

There is a ton of information on insurance coverage for ADR in "The Big Bucket" forum on this website.

The discogram can be an uncomfortable procedure. However, if a disc is found to cause pain they stop applying pressure with the needle and pull it out immediately.

Please keep us updated on your progress.

Justin

[Dale S]

Hi Laura,

Join the crowd. I was scheduled for my 3 level adr and 1 fusion yesterday until BC applied the brakes. My claim was denied as was my appeal but their denial letter contained an imcomplete medical history. I again appealed yesterday... this time offering to share the costs of the Charite discs beyond my policy limits, since this seems to be the only difference between adr and fusion surgery.

Don't know the outcome yet, but will post if they accept and authorize my surgery.

Should BC deny coverage...do not appeal to the California Dept. of Managed Health Care (thank you insurance problems) since they have NEVER overturned a denial of adr coverage. You can check their database yourself.

I am sorry for your pain and suffering and wish you luck. I have found this forum to be both comforting and informative... and even a little alarming... but knowledge is power.

Dale

[Laura C]

Hi Dale,

I had a discogram today which showed 3 positive levels. One which has a facet joint missing. I find this whole insurance situation ludicrous, however, if some BC insurances are approving the procedure, perhaps it will not be long. I don't know how much longer I can hold out, but I am hoping for some changes in their policies. Tell me a bit about your condition and insurance. I am also a patient of Dr. Regan -

Laura

By the way, those that are fearing the discogram, it was not as bad as I thought it would be - they gave me some pain meds (IV) afterwords. The whole experience was not too bad.

[Dale S]

Laura,

After rupturing s1/l5 in '94, (I have one leg longer than the other) it's been downhill from there. Failed back surgery syndrome and I now have 4 bad levels. The disc space at s1/l5 to very narrow and a fusion was recommended along with a 3 level adr. Enter BC who claims that adr has only been shown to be equal to but not superior than fusion and therefore is still investigation.... You know the rest.

They denied my claim and my appeal, explaining that I should then utilize the DMHC for an independant review. Of course they would do that, the DMHC has never overturned an ADR denial. Their rejection letter did not contain my complete medical history so I've appealed again.

I also found Cedars to be difficult to negotiate with. I had hoped to pay them what BC would have... but they only give a 60% discount to cash patients and charge close to $20k for the discs themselves... which is almost double the retail price????? I'm hoping the Doctor's Hospital, opening soon will be more reasonable.

Laura, I wish I had words of wisdom but in another post, I pointed out that until studies show adr's are in some way superior to fusion, the insurance companies will have a basis for denial. Why some pay and other don't... no one seems to know. Why some both authorize and deny coverage... again, it's a mystery. You would think we would have some power in numbers but...

I should be in the hospital as I write this, complaining about the pain and grateful that the surgery is behind me. Instead, I'm more despressed than ever and feeling very sorry for myself. I don't know what comes next or when. And of course, there's always Germany. But I will tell you that I intend to fight. I may consult with an attorney if my offer to split costs is also denied... or perhaps arbitration.

Have you spoken to Mark ******* at GlobalPatientNetwork.com. He can't help you with insurance problems but is very knowledgable and might be able to answer some questions for you.

I understand your plight and sympathize with your life, or lack of it. Hang in there Laura.

Dale

[Laura C]

Dale,

I so understand your frustration and depression. I intend to fight furiously for them to pay. I have to say I somehow feel that coming upon a year since the FDA approval coupled with the fact that some BC's are approving the surgeries, that it won't be long. I just have this feeling and a woman's intuition should never be ignored! I am not going to settle for a 3 level fusion. I will hold out for insurance to pay. In the meantime, I will have to rely on my meds and be really careful not to do anything to further my deterioration. Dr. Regan said to me a week ago, to be persistant with the insurance company. I felt the same devistation when I got my first denial letter. However, I do feel that this cannot continue. There are so many of us in this situation. I wonder what would happen if a Blue Cross employee were in our shoes???

I will keep you posted - think positive and hang in there.

Laura

[ans]

I saw Delamarter's partner, Kropf, a while ago. He told me that BC of CA will be the last holdout. I should have asked why. I wish you guys luck. I tried to get a straight answer from BC's Utilization Review if they have authorized any ADR's to no avail - a stone wall.