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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 10-31-2013, 08:31 PM
CCFour CCFour is offline
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Join Date: Oct 2013
Posts: 3
Default Tricare covering ADR

I am in the military and have seen that tricare would not cover ADR.
i have 2 disc's l5-S1 and l4-l5, the Doc informed that fusion would be an option but ADR would be more beneficial due to my activity level and age (26).
would less likely have affect on the other disc's over a long term.

I would like to know if any one ells has had the same issues, and how to get tricare to stand up to a proceeder that has been recommended by 2 neurosurgeons.

I have 6yr in AD
i have done 3 months of PT
completed 3 injections of cortisone.
and currently back on PT and going for a 3rd referral for this back issue.
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  #2  
Old 11-01-2013, 12:19 PM
Jerry5 Jerry5 is offline
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Join Date: May 2013
Posts: 363
Default Option

CC Four,
The Military will only accept what is 'common practice' accepted by the FDA.
I read once, where a Major in the Marine Corp, had a couple replaced, ADR, with Charite, (in Spain) but there are a number of cases where they are failing or causing complications.

Charite™ Spinal Disc - Charite Disc Complications

{this may be why the US FDA is refusing to approve the M6}

My best recommendation is to go to spain, the UK or Germany, and have a two level M6L.

Look up German Spine Institute, this surgeon, has the best record that I can find, over 1,000 of these, with good to excellent long term outcomes.

If had known how bad my lower back was, (this caused problems on the upper lumbar, to have required surgery and now affecting to lower even more) I would have done the two lower discs a long time ago. (Now looking at a 3 level, L45, L5S1 and the L23)

Go for it, it will cost you about $30K(your two level), but it will be worth it. (this is like dominos, cascading, if you keep the lower two moving, the rest of your spine will stay healthier, this is how the discs get nutrients, by moving)

contact spine solution

Send them your MRI, you can get a copy of the MRI, and use a repository, like DropBox, and upload that file there, up to 2 Gig, and send them the link, easy to register.

Good luck, I am waiting for VA/Insurance approval, if you can appeal the decision by the military, did not deal that much with them when active, but there must be recourse, look for a PA, patient advocate, MMSO or since you are on PT, you may be able to contact the VA, try everything, you CANNOT accept the Fusion, with 14 more years looking at you and your age, this is unacceptable.

Jerry
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  #3  
Old 11-01-2013, 07:03 PM
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LauraB LauraB is offline
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Join Date: Jul 2013
Posts: 175
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CCFour,

Like you, most of us are in the same predicament regardless of the policy. The insurance will generally pay for the standard procedure (usually fusion), but some will cover the FDA approved ADR's if it fits their ever-changing criteria. Since the more popular M6 is not FDA approved, you probably need to consider this as an out-of-pocket expense with hopes of some return on the medical portion of your taxes. There are a few cases of BCBS covering the procedure and I'm in the process myself.

Given your age, it would be well worth your while to address this issue. With your pain and health in control, you have the opportunity to work and easily gain back this "investment" in yourself. In perspective, people spend as much on a car and it depreciates or is cast aside within a relatively short time. The expense and quality of surgery in Europe is well worth the inquiry.
__________________
2006 C 5/6 discectomy and fusion
2008 Automobile Accident
C3/4 leftward bulging of intervertebral disc mild narrowing of left lateral recess
C4/5 central and rightward bulging of disc and osteophyte causing mild right neural foramen stenosis narrowing and right lateral recess narrowing
C6/7 Central disc bulging and osteophyte and hypertrophy of ligamentum flavum canal stenosis and narrowing of bilateral neural foramina
Sept 9, 2013 Scheduled with Dr. Bierstedt C4/5 & C6/7 M6
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  #4  
Old 11-01-2013, 07:50 PM
Jerry5 Jerry5 is offline
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Join Date: May 2013
Posts: 363
Default CC Four, Laura

I stated this would be about $30K, that was Euros, this would be about $38K US Dollars, but again, depending on your rank, and if you have re-upped recently, they will look at this, for longevity, you may consider a loan.

If you make the military a career, it is almost a no brainer.

I really cannot understand the logic, of the military, only giving the fusion option, and I would beg to ask, wouldn't this make you medically unfit (third person) for active duty?

Did this happen in an accident on active, during your normal activities?

Document this to the nines, make sure you have paper and electronic copies of EVERYTHING.

If this did happen on active duty time, I would seek Counsel, maybe go to the JAG, and certainly, go off base, or to other areas of the Defense, a local base or so on, will most likely give you SOP protocol for the treatment.

Again, this M6L, has been tested to eight times the human loading for over 20 million cycles, equivalent to 80 human years, and showed negligible wear.

keep in touch, and there are solutions, being on active duty is not going to make this easy.

Even as a civilian, it is very difficult.

Jerry
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  #5  
Old 11-01-2013, 07:57 PM
Jerry5 Jerry5 is offline
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Join Date: May 2013
Posts: 363
Default PT

One word of caution, and I really, 100%

Disagree with this, especially if you have a herniation of the, or more than one disc.

I have consulted more than one or two, neurosurgeons and specialists, (they did not press me to do PT-it may do more damage) really think twice about all this PT, Physical Therapy, make sure you have an MRI and know where the 'leak' is(in my case, it was more or less a blowout, and two days later I was laying flat for two days), and how and where it is impinging the nerves, movement in my case would have made it worse.

Food For thought, having your MRI is essential, if need be, pay $400 off base, and see the results for yourself.

I cannot imagine being on active and dealing with this.

Did they give you any pain meds, like Codone?

OTC will not take care of this kind of pain.


Jerry
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  #6  
Old 11-02-2013, 07:31 AM
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LauraB LauraB is offline
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Join Date: Jul 2013
Posts: 175
Default

I sooooo agree with Jerry regarding PT. Physical therapy will help strengthen muscle and create a strong core, but when there is damage to the spine - this can not only create more pain, but could exasperate the damage. For some reason, many insurance protocols non-invasive treatment prior to surgery - which is good. However, the MRI should be the first priority. I found that the PT left me debilitated for days after - I had to give it up, and I'm somewhat athletic.
__________________
2006 C 5/6 discectomy and fusion
2008 Automobile Accident
C3/4 leftward bulging of intervertebral disc mild narrowing of left lateral recess
C4/5 central and rightward bulging of disc and osteophyte causing mild right neural foramen stenosis narrowing and right lateral recess narrowing
C6/7 Central disc bulging and osteophyte and hypertrophy of ligamentum flavum canal stenosis and narrowing of bilateral neural foramina
Sept 9, 2013 Scheduled with Dr. Bierstedt C4/5 & C6/7 M6
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  #7  
Old 12-10-2013, 09:15 PM
CCFour CCFour is offline
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Join Date: Oct 2013
Posts: 3
Thumbs down Got A NO-GO

I just got told by my Tricare that they will not cover my ADR for the lumbar regain.
I was told that it is FDA approved but on the government no pay list, and un-proven.
I would like to know how long does it take for it to be proven and why would they still allow fusion when it has been show to harm in the long run.
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