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Old 09-07-2011, 06:01 PM
laid up doc's Avatar
laid up doc laid up doc is offline
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Default Aetna - anyone had out of country ADR or fusion covered???

See my signature below.... I've exhausted my non-surgical options and am looking at surgery options. I'm having allergy testing next week, but per Prodisc's website, a person getting a prodisc "Must not be allergic to cobalt, chromium, molybdenum, polyethylene or titanium". I'm definitely allergic to nickel, and fear being allergic to any of those other things. Am being tested formally next week, patch testing and LTT blood work.

I feel like i'm in a pickle and in for a big fight.... but still trying to figure out what to fight FOR. I'm hoping SOMEONE out there has won an appeal for 1. out of country ADR for device not available here, or 2. fusion for disc pain...

1. Aetna states that they only cover FDA approved single-level ADR. Which is great, for a lot of people... but not for ME. Prodisc is the only disc currently being made in the US. There are still some Charite's out there, but both contain cobalt and chromium. I'm a highly atopic individual... lucky me. There are titanium discs in Europe - particularly the M6L. I spoke w/ Aetna today - they say they aren't in network w/ any international docs, and my policy covers emergency treatment only.

2. Aetna states that they don't cover fusion for discogenic pain. Isn't it great that 2 of my surgeons unequivocally hate lumbar ADR's and suggest fusion. I would love love love to know of a precedent where Aetna has covered fusion when the ADR available here is contra-indicated.

If anyone has any input on these 2 scenarios, please contact me by PM or on this thread. thank you!!!
__________________
US non-spine MD - laid up no more!!!
had recurrent annular tear L5/S1, failed everything
M6L done 10/19/11 w/ Dr Clavel getting back to my old self more and more every week!
laidupdoc@gmail.com if my PM box is full

The content herein represents my professional thought and opinions in a general sense only; they do not constitute professional advice or services. if you need medical advice, please consult a licensed physician.
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Old 09-08-2011, 12:23 AM
janaya3 janaya3 is offline
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Originally Posted by laid up doc View Post
See my signature below.... I've exhausted my non-surgical options and am looking at surgery options. I'm having allergy testing next week, but per Prodisc's website, a person getting a prodisc "Must not be allergic to cobalt, chromium, molybdenum, polyethylene or titanium". I'm definitely allergic to nickel, and fear being allergic to any of those other things. Am being tested formally next week, patch testing and LTT blood work.

I feel like i'm in a pickle and in for a big fight.... but still trying to figure out what to fight FOR. I'm hoping SOMEONE out there has won an appeal for 1. out of country ADR for device not available here, or 2. fusion for disc pain...

1. Aetna states that they only cover FDA approved single-level ADR. Which is great, for a lot of people... but not for ME. Prodisc is the only disc currently being made in the US. There are still some Charite's out there, but both contain cobalt and chromium. I'm a highly atopic individual... lucky me. There are titanium discs in Europe - particularly the M6L. I spoke w/ Aetna today - they say they aren't in network w/ any international docs, and my policy covers emergency treatment only.

2. Aetna states that they don't cover fusion for discogenic pain. Isn't it great that 2 of my surgeons unequivocally hate lumbar ADR's and suggest fusion. I would love love love to know of a precedent where Aetna has covered fusion when the ADR available here is contra-indicated.

If anyone has any input on these 2 scenarios, please contact me by PM or on this thread. thank you!!!
1. Unless your Aetna plan is a fully self administered and funded plan like mine you are probably not going to have much luck having someone high in the chain of command approve an out of the country procedure like the one you are seeking as an option especially if the Prodisc is available in the US even with your pending allergy testing. And while I am no expert on metal allergies but have friends who are immunologist, I wonder if the titanium will also pose any cross sensitivity risks to your nickel allergy. Additionally the M6 has no FDA approval in the US and that is the first thing Aetna will claim in order to avoid paying for the procedure but like you and I already know it is mere politics and Synthes the mfg of the Prodisc has called foul play (patent right infringement) on the keel design that prevents the use of the M6 in the US. You may however be successful in having them overturn their stance (Clinical Policy Bulletin) by having them cover a fusion for discogenic pain if your allergy testing contraindicates the Prodisc L or Charite.

In my personal experience I almost went this extra route when I was initially unable to find a neurosurgeon who was up to date on the modern advancements of ADR as well as performed such surgeries. I had no other choice so I began the "alternate" process by calling a former colleague of mine who currently is now one of like twenty Vice President at our hospital-- coincidentally Vice President of Operations for Ambulatory and Surgical Services at our hospital-- to seek his advice. He is very well spoken, intelligent and easily put me in contact with one of his connections-- an individual within the hospital Human Resources department who was instrumental with most of the policy and underwriting for our Aetna plan. If anything I believe he would have probably made the call to "that higher being" in order to have certain policies overturned in my favor. I have heard of case by case scenarios being overturned despite what certain information Aetna may quote and this was my logic for seeking this "alternative" route. Luckily I was able avoid it all together as I was able to find a great neurosurgeon who was competent and was all in favor of the artificial disc given my history, characteristics and his knowledge of ADR and spine mechanics.


2. Although not comforting to know and perhaps not the easiest most stress free process to undertake is the appeal process. I have been, in my opinion, lucky on winning a few appeals for totally unrelated issues in the past but it was time consuming and stressful. Sometimes to the point that I just wanted to quit and give in.

3. Hopefully your formal allergy testing confirms that you are a candidate for the Prodisc or M6-- whichever route you decide on. I know that you still have concerns about ADR vs. fusion from reading your other posts. But I hope that you can clear you mind and are able to make a clear and concise decision because no one deserves to live in pain. I know it is difficult because you have many factor or variables such as your pending lawsuit which limits your choice(s) and if you are anything like me very analytical and critical it is a tough decision to make. I know that it was a difficult road for me and not an easy decision but I must tell you that I am happy to have done the Prodisc L. I-- like you-- wish that the M6 was another option available in the US but unfortunately that is the nature of the beast and I really didn't want to act selfish and spend our savings to travel abroad to have what is probably considered a more advanced artificial disc placed in me. I also still ponder what the future will hold for me and my Prodisc/spine in the next 2, 5, 10, 20 years but I prefer to take it one day at a time and enjoy my children, my life and a world free of pain!

Please keep all of us updated as to the results of your allergy testing and your decision. Your case is very unique. Good Luck!!!!!!
__________________
36 YO male with L4-L5 DDD of idiopathic etiology
Successful Surgery w/ Prodisc L Aug. 25, 2011 (size Medium, 6 degree lordotic angle w/ 10 mm PE inlay)
CURRENTLY 85-90% IMPROVED!!!!!!!!!
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  #3  
Old 09-08-2011, 12:42 PM
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janaya -

i will be tested for titanium as well, but it's much less common that nickel or chromium allergies. i am analytical beyond analytical... since i'm unable to work anymore i spend a lot of time doing research, trying to decide what the best thing for me to do is.

if i am not a candidate for a prodisc, i will most likely find the $$ to pay for whichever surgery i think is best, and deal with the appeals after the fact. it costs me a tremendous amnt of $$ not to work (i'm a specialist MD) and my COBRA runs out in May. plus, waiting and fighting aetna will destroy my mental health. also, once i have some resolution then i can proceed w/ the lawsuit - which may in some ways take aetna out of the picture.

i am having a HUGE problem getting a consensus from docs though... one thing that will be a problem should i choose to do an ADR overseas. the 2 docs i saw where i live now both said fusion, that they did adr's and stopped.

i saw a neurosurg in another city (to which i am moving shortly) who just does fusions... and since i am a great ADR candidate as far as my diagnosis, he wanted his partner who does a lot of ADR's to review my case. well, i'm having a lot of trouble even speaking to this dude on the phone. seems once they found out i wasn't a candidate for one of their studies, they weren't interested. apparently most of the insurers in that area don't cover ADR, and they didn't seem to believe me that I had a policy that did. his secretary said some extremely rude things on the phone... i don't know if these are the surgeon's words or hers but it was extraordinarily rude and unprofessional. really turning me off... usually fellow docs don't treat another doc like that, or any medical professional for that matter. ugh.
__________________
US non-spine MD - laid up no more!!!
had recurrent annular tear L5/S1, failed everything
M6L done 10/19/11 w/ Dr Clavel getting back to my old self more and more every week!
laidupdoc@gmail.com if my PM box is full

The content herein represents my professional thought and opinions in a general sense only; they do not constitute professional advice or services. if you need medical advice, please consult a licensed physician.
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Old 09-08-2011, 11:52 PM
janaya3 janaya3 is offline
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Originally Posted by laid up doc View Post
janaya -

i will be tested for titanium as well, but it's much less common that nickel or chromium allergies. i am analytical beyond analytical... since i'm unable to work anymore i spend a lot of time doing research, trying to decide what the best thing for me to do is.

if i am not a candidate for a prodisc, i will most likely find the $$ to pay for whichever surgery i think is best, and deal with the appeals after the fact. it costs me a tremendous amnt of $$ not to work (i'm a specialist MD) and my COBRA runs out in May. plus, waiting and fighting aetna will destroy my mental health. also, once i have some resolution then i can proceed w/ the lawsuit - which may in some ways take aetna out of the picture.

i am having a HUGE problem getting a consensus from docs though... one thing that will be a problem should i choose to do an ADR overseas. the 2 docs i saw where i live now both said fusion, that they did adr's and stopped.

i saw a neurosurg in another city (to which i am moving shortly) who just does fusions... and since i am a great ADR candidate as far as my diagnosis, he wanted his partner who does a lot of ADR's to review my case. well, i'm having a lot of trouble even speaking to this dude on the phone. seems once they found out i wasn't a candidate for one of their studies, they weren't interested. apparently most of the insurers in that area don't cover ADR, and they didn't seem to believe me that I had a policy that did. his secretary said some extremely rude things on the phone... i don't know if these are the surgeon's words or hers but it was extraordinarily rude and unprofessional. really turning me off... usually fellow docs don't treat another doc like that, or any medical professional for that matter. ugh.

Interestingly enough once I found a neurosurgeon in my area that dealt with ADR I thought I was set and said to myself something like: I like how things are now starting to favor my way. THEN I get a call from the neurosurgeon's office and a young lady with perhaps no proper medical training or background-- who I will not name-- blatantly tells me my scheduled Prodisc L procedure is NOT covered. Oh yeah and she tells me this 3 weeks prior to my surgery date! I ask her to substantiate her claim and remains speechless but continues to utter that my policy does not cover the specific procedure. But me, I wasn't really worried. I politely explain to her that she has to be mistaken and is speaking in a general context because I literally must have researched my particular Aetna's policy stance, Clinical Policy Bulletin and all other pertinent info pertaining to my surgery like I was defending my dissertation, and yet despite me literally quoting verbatim information, she turns RUDE and becomes somewhat combative and argumentative--almost to the point of being a snob with me and insists it is not covered. I then just ignored our conversation and told her to go ahead and have her "people" i.e. whatever department handles the formal insurance verification process and get back to me. I think then I became weary and grew doubtful about the practice, and thought to myself, maybe I don't want this practice doing my surgery but overall it was a mere office personnel, in my professional opinion, with no formal training stating what she thought was correct...that in fact MOST insurances don't reimburse/cover intervertebral disc prosthesis surgery! The neurosurgeon on the other hand was tremendous and did an outstanding job! I am starting to wonder if we are dealing with the same people here!

I sincerely do hope and pray that the outcome(s) favor your way too!
__________________
36 YO male with L4-L5 DDD of idiopathic etiology
Successful Surgery w/ Prodisc L Aug. 25, 2011 (size Medium, 6 degree lordotic angle w/ 10 mm PE inlay)
CURRENTLY 85-90% IMPROVED!!!!!!!!!
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