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Insurance Hell All insurance-related matters are here: Medicare, worker's compensation, appeals, denials, insights, wins, losses. PRICING is here too. Note: This forum has posts from 2006 forward. Older ones are in the Big File.


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  #1  
Old 01-16-2011, 03:36 PM
MustangO3 MustangO3 is offline
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Default ALIF Denied by Tricare, where to go from here....

My wife had a back injury in 1998 and it has progressively gotten worse. The last four years being the worst. She has been diagnosed with DDD in L5/S1.
She went through the pain clinic routine and injections with minimal to negative results.
She then had a spinal cord stimulator implanted for a year that even had an adjustment half way through when it wasn't working. It was finally removed this last year after it did nothing and actually caused pain in additional places in her back. (3 unnecessary surgeries)

We then were referred to a spinal surgeon who recommended an ADR, but as I am in the Marines, Tricare will not authorize it, so they submitted for an ALIF. Tricare came back and required a Discogram, so that was another painful procedure.

We went for the second opinion and the other surgeon confirmed the ADR is preferred, but the ALIF should be able to help some. Our primary surgeon seems a little overly positive that the ALIF will get her back to 100%. This has created a shadow of doubt that this is the way we should go.

We just received the denial letter from Tricare because they claim it will not resolve the problem.

Additionally, our current surgeon made a "mistake" on my wife's pain meds, so we are in a tough spot right now. We don't have a lot of confidence in our doctor, the insurance is shooting us down, and we are not sure who to turn to with regard to fighting insurance, finding the right doctor etc.

So, I will continue reading here and i hope this serves as an introduction, and any encouragement, crazy ideas etc, would be appreciated. Thanks for providing a good resource-John
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Old 01-16-2011, 09:14 PM
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Harrison Harrison is offline
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John,

It's been some time since I looked into Tri-Care, but I can tell you that MANY military Tri-Care members were covered for ADR and fusion.

If you have not already done this, do a quick search (the search utility works great!) using tricare and tri-care, that should get you started.

It's crazy that you are putting your wife through this! One consoling thought here: many one-level patients (most) do very well with ADR in their recoveries.
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Old 01-16-2011, 09:18 PM
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Harrison Harrison is offline
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Default Here's one of many...

...but you have to dig. See Cervie Queen's post...
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"Harrison" - info (at) adrsupport.org
Fell on my ***winter 2003, Canceled fusion April 6 2004
Reborn June 25th, 2004, L5-S1 ADR Charite in Boston
Founder & moderator of ADRSupport - 2004
Founder Arthroplasty Patient Foundation a 501(c)(3) - 2006
Creator & producer, Why Am I Still Sick? - 2012
Donate www.arthropatient.org/about/donate
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Old 01-16-2011, 09:39 PM
MustangO3 MustangO3 is offline
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Thanks for the reply. Believe it or not I am not putting her through this, tricare is. We are attempting to reenforce our rebuttal now and with any luck the fusion will be approved. What we are hearing is that ADR is getting approved for active duty but not spouses. It is insane. And now that she doesn't trust her doctor it makes it even more frustrating. Thanks again for the response. We will keep fighting. I am even looking seriously into an out of pocket option. I am so glad I pay taxes...John
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Old 01-21-2011, 07:52 PM
MustangO3 MustangO3 is offline
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We got accepted to be seen at Balboa Nuero! Insurance is not an issue now! Wish us luck.....
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Old 01-21-2011, 08:18 PM
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Good luck! What are you next steps?
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Fell on my ***winter 2003, Canceled fusion April 6 2004
Reborn June 25th, 2004, L5-S1 ADR Charite in Boston
Founder & moderator of ADRSupport - 2004
Founder Arthroplasty Patient Foundation a 501(c)(3) - 2006
Creator & producer, Why Am I Still Sick? - 2012
Donate www.arthropatient.org/about/donate
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Old 01-21-2011, 10:24 PM
MustangO3 MustangO3 is offline
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We are going to schedule the initial consult on Monday. I had to find the name of the chief of the Nuero department and plead my case to make sure ur would be seen. After getting him on the phone he was very nice and confident that they could help. We are very excited. It was posts here that got us in the right direction on this. Thanks again.
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Old 02-17-2011, 12:47 PM
MustangO3 MustangO3 is offline
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WE ARE IN!!!
Scheduled for surgery the last week of May at Balboa. We will be getting an ADR as opposed to an ALIF and as our original doctor recommended that, we are very happy. He even said that the money is not an issue there, so they will do what they think has the best chances for succeeding.

It took some fenagling to get in there, but we got to meet with the nuero head there and he will be doing my wife's surgery.

We asked about how other dependents could get there and he said that Balboa is now considering dependent referals from primary care doctors, so if you have been denied before, try again.
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