New Member

[thumoeides]

New member introduction.

On January 15 I had severe left shoulder pain. My GP first diagnosed bursitis, gave me prednisone and muscle relaxents. No improvement one week later and GP referred me to a physical therapist. Two weeks later with no improvement I asked for a referal to an orthopedic surgeon who ordered X-ray of my shoulder and MRI of my shoulder and neck as I reported shooting pains down my left arm. He also gave me a steroid shot to the shoulder.

He referred me to a neurosurgeon when he saw the MRI which indicated degenerative disc disease. The neurosurgeon said I need immediate anterior discectomy and fusion of C5-C6 and C6-C7. He noticed weakness in the left arm and lack of triceps reflex. But he said I could wait another two weeks and gave me 30% chance of recovery with more prednisone and perscription naproxen.

I went to a second neurosurgeon for a second opinion who said I should try two more weeks of physical therapy and ordered a CT scan of the cervical spine because the MRI was not clear on C6-C7 herniation. He said I had a detectible reflex in my left triceps.

Physical therapy helped with severe shoulder pain. Can avoid pain if I keep my head down, but left arm pain and shoulder pain return if I lift my head up or bend it back.

Saw second neurosurgeon for again in two and a half weeks time. He said surgery was necessary. No triceps reflex. He said either two level discectomy and fusion, or single level disc replacement. Since C5-C6 seems to be asymptomatic, although future surgery at that level might be necessary, he said the disc replacement at one level made sense. Although both options could lead to good results, if it were him he would choose disc replacement.

Medtronic, the maker of the Prestige disc, would use Therapy Access Solutions to prepare the request for predetermination for the Prestige disc to Blue Cross Blue Shield of Texas.

Request letter and supporting documents were faxed to BCBS on 3/26. It has now been three weeks with no decision.

I am wondering what an average wait time for a decision is. I have read here that BCBS of Texas has approved disc replacement in the past. I have called both Therapy Access Solutions and BCBS several times and been told a decision should come in the next few days, but no guarantees.

I am thinking of calling my surgeon and asking him to call BCBS to say the surgery is urgent because the longer the wait time the worse my chances of full recovery of muscle use are.

Any advice?

[Harrison]

Hey "Thum," thx for finding us. Some people who have docs that are able to argue within the terms of medical necessity have better luck than non-urgent cases. I can share more at a later date and privately as well. I prefer to not provide too many details like this in public!

Any way, can you tell us more how degenerated your cervical discs are? The extent of herniation? Pain? Disability? Thx for covering most of this in your signature...

[thumoeides]

I am not sure how to measure the extent of herniation. If I understand the question rightly, the MRI report speaks of a C6-C7 left foraminal disk protrusion, which as I understand is better than an extrusion. The CT scan report of a left foraminal herniated disc with some extension below the disc line without specifiying whether it is a protrusion or extrusion.

At C5-C6 there is disc degeneration with a loss of disc height, posterior disc bulging and mild to moderate central canal stenosis as well as moderate bilateral neural foraminal stenosis. But there appear to be no symptoms from that.

I have left arm and shoulder radicular pain which varies because if I keep my head bent down I can relieve the pressure on the nerve and thus the pain. I also have significant muscle atrophy and weakness of the left pectoral muscle, the triceps and the wrist extensor. All that seems to be caused by the herniation at C6-C7.

I would appreciate any help in getting BCBS to make a decision.

What does it mean to argue within the terms of medical necessity? Can that even be done prior to getting a decision from the insurance company?

I was told by the woman who prepared the predetermination letter--she works for Therapy Solutions which is hired by Prestige to handle these things--that BCBS will not be influenced to move more quickly by anything less than life threatening problems.

[thumoeides]

I found out about my insurance approval on Friday, and on Saturday I received a call from the hospital for preregistration for a surgery on May 6.

So my predetermination request was made on March 26, and official approval was made on April 20. I was informed when I called on April 23 that a letter had been mailed to me and my surgeon. Letters are only faxed when the surgery is urgent I was told.

The hospital told me the surgery without insurance would cost $33,353.59.

I am getting the Prestige artificial disc at C6/C7.