List of Who has been denied ADR

[LBP]

thanks for the clarification because otherwise it seems like a very accelarated wear and tear of an otherwise healthy adjacent level disc...which would be scarey info!

It will be interesting to watch your recovery over time since you have the fusion at 4/5 with ADR at l5/S1. Normally in a "hybrid" situation,it seems preferrable to put the adr at l4/5 and fusion at the less mobile level of L5/S1. Because of your circumstances with the trial restrictions....yours seems to be a little abnormal or at least the opposite of what others have done before when having one hybrid surgery.

would like to hear about your fusion experiences at l4/5.

[phylly]

Hello LBP,
I am new and I am chiming in. I was denied for a two level prodisc L4-S1 by two separate policies, Blue Cross and Blue Shield. I appealed for an IMR and was denied again. I won't give up yet. I paid cash for my surgery. My goal is get so much better that I can prove my surgery was valid. How is your research going?
Phylly

[Lisibug]

I had Blue Shield HMO insurance and was denied any ADR surgery, but I was indicated for 3 levels. I also asked about seeing Rick Delamarter in Santa Monica, CA, who is only 45 minutes from me, because he is an excellent surgeon performing ADR surgeries and clinical trials, but they would not cover me seeing him, either. My NS (the only one in my area) does not perform ADR surgery. In 3/07 I went to Dr. Bertagnoli and am much better as a result.

[riley222]

I was denied coverage by United Healthcare even after 4 appeals and ultimately payed all expenses out of pocket for a single level ADR in Feb 2006. UHC stated that there is not enough long term research results so they deem it as still an investigational stage device. I reside in Durham, North Carolina. My doctor submitted an official complaint to the North Carolina Insurance commissioner and included all his patients who were denied and their respective insurance companies justifications at that time but with no luck.
Good luck with the list! I was looking for something like this before my surgery.
Take care,
Riley

[Slackwater]

Originally posted by LBP:
I would like to start a list of people who still have been denied ADR surgery by their insurance company.

CIGNA denied 2-level ADR Request Sept 2007
CIGNA denied 2-level ADR 1st Appeal Nov 2007 (? look-up item on the appeal date ?)

Cigna wrote I have one (1) appeal left. I hesitate to believe what Cigna wrote without reading the insurance policy. Cigna saw there was an auto-accident & lawsuit. Surgeons may think symptoms are exaggerated, see "Validity of Self-Reported History in Patients with Back and Neck Pain after Motor-Vehicle Accidents (MVA) , NASS 2007 Annual Mtg. CIGNA's "ADR / TDR Coverage Position" is single-level only. Cigna will not pay for a hybrid surgery, ie.
<UL TYPE=SQUARE>ADR L4/5
Fusion L5/S1[/list]CIGNA will pay for a two-level fusion.

Litigation is a conta-indication for Fusion or ADR, I suggest. My litigation is over. Symptoms are still here. Somehow I thought I must be fabricating pain?? What was I thinking? Oh, right, no fusion because of "long-term outcomes", re-operation rates and adverse events. Is there an alternative, uhh, what's ADR/TDR?

P.S. UCSF, a trial site for Prodisc, was my last surgical evaluation of 4 surgeons. UCSF helped with the request / appeal. UCSF may possibly track the number of ADR denials as an adjunct to the FDA trial, just an impression, no hard data.

[Liz]

Originally posted by Slackwater:
CIGNA denied 2-level ADR Request Sept 2007
CIGNA denied 2-level ADR 1st Appeal Nov 2007 (? look-up item on the appeal date ?)

Cigna wrote I have one (1) appeal left. I hesitate to believe what Cigna wrote without reading the insurance policy. Cigna saw there was an auto-accident & lawsuit. Surgeons may think symptoms are exaggerated, see "Validity of Self-Reported History in Patients with Back and Neck Pain after Motor-Vehicle Accidents (MVA) , NASS 2007 Annual Mtg. CIGNA's "ADR / TDR Coverage Position" is single-level only. Cigna will not pay for a hybrid surgery, ie.
<UL TYPE=SQUARE>ADR L4/5
Fusion L5/S1[/list]CIGNA will pay for a two-level fusion.

P.S. UCSF, a trial site for Prodisc, was my last surgical evaluation of 4 surgeons. UCSF helped with the request / appeal. UCSF may possibly track the number of ADR denials as an adjunct to the FDA trial, just an impression, no hard data.

Slackwater -- if Cigna's policy covers one level ADR why won't they cover a hybrid?? If you haven't already, you should request all of Cigna's documents, internal rules, guidelines, etc relevant to your appeal for benefits coverage for ADR. you are entitled these documents and there should be language to this effect in your denial letter. however, you need to request them NOW before your appeal window closes. although i was unsuccessful in obtaining coverage, i found these documents very helpful for my final appeal... my carrier had copies of many of the ProDisc studies which compare favorably to fusion so I cited data in the documents United Healthcare was using to deny coverage back at them, stating I believed they had misapplied Plan provisions b/c of such and such data in their documents, FDA approval, nothing in my policy through my employer specifically excluding ADR, etc. Anyway, I hope you have better luck w/your final appeal, esp since they'll allow a single level. i know the process is infuriating to say the least. United would not even approve a single level, but I kept appealing b/c they never denied my claim because I needed 2 levels, they just denied b/c experimental/unproven.
best of luck,
liz

[LBP]

just to clarify.

I am not actively working on some big lawsuit ...researching law firms etc because a long time ago, someone posted research about fed laws precluding bad faith type lawsuits.

I still think it's important to share stories and keep an active list going. In some situations someone might be able to help an individual case and worst case...at least you know you're not alone in getting denails when you wonder how the list of those post ADR surgery continues to grow!

[Slackwater]

Originally posted by Liz:

Slackwater -- if Cigna's policy covers one level ADR why won't they cover a hybrid?? If you haven't already, you should request all of Cigna's documents,
liz

First, thank you for thinking of me. It's appreciated. Good question on "<span class="ev_code_BLUE">Hybrid</span>".

You wrote Hybrid and I suggest(?) you are on the right track and synchronized wth the surgeons posting results of "Hybrid" surgeries. In parallel there are papers published debating which lumbar level should be fused v. ADR.

You mentioned <span class="ev_code_PURPLE">CIGNA's ADR policy</span>, ... paperwork items. Cigna's coverapge position was in my briefcase when I went to see the Orthopaedic surgeon at UCSF last year. The Cigna coverage postion is found here, HERE. No big need to read unless you have Cigna. I see the coverage position is updated since I last read it, but the net results is the same. I will try cut-and-paste below so people stay in no-surprise mode.

===============================================
Coverage Position
Revision Date 12/15/2007

CIGNA HealthCare covers the surgical implantation of a Charité® or ProDisc®-L lumbar
intervertebral disc (IVD) prosthesis for chronic, unremitting, discogenic low back pain and
disability secondary to single-level degenerative disc disease (DDD) as medically necessary in a
skeletally mature patient when ALL of the following criteria are met:
<UL TYPE=SQUARE><LI> The unremitting low back pain and disability described has been refractory to at least six consecutive months of standard medical and surgical management (e.g., exercise, analgesics, physical therapy, spinal education).
<LI> Single-level disc degeneration has been confirmed on complex imaging studies (i.e.,
computerized tomography [CT] scan, magnetic resonance imaging [MRI]).
<LI> The planned implant will be used in the L4-S1 region if Charité or the L3-S1 region if ProDisc®-L.[/list]CIGNA HealthCare does not cover the surgical implantation of any of the following because they are considered experimental, investigational or unproven:
<UL TYPE=SQUARE><LI> A Charité or ProDisc®-L lumbar intervertebral disc prosthesis when any of the following apply:
<LI>> The planned procedure includes the combined use of a prosthesis and spinal fusion.
<LI>> Simultaneous multilevel implantation is planned.
<LI>> The implant will be inserted outside of the L4-S1 region (Charité) or outside of the L3-S1
region (ProDisc®-L).
<LI>> The patient has osteopenia or osteoporosis (T-score < -1.0).
<LI>> The patient has a history of prior lumbar fusion.
<LI>> There is evidence on imaging studies of ANY of the following:
<LI>•• degenerative spondylolisthesis of Grade 2 or greater
<LI>•• infection
<LI>•• multilevel degenerative disc disease
<LI>•• nerve root compression or spinal stenosis
<LI>•• pars interarticularis defect with either spondylolysis or isthmic spondylolisthesis
<LI>•• scoliosis
<LI>•• severe facet joint arthrosis
<LI>•• spinal fracture
<LI>•• tumor
<LI> A lumbar disc prosthesis other than Charité or ProDisc®-L[/list]CIGNA HealthCare does not cover the implantation of cervical intervertebral disc prosthesis (e.g., PRESTIGE™ ST) for any indication because it is considered experimental, investigational or unproven.
======================================


Agree with you, I should get on with the next, Last(?) appeal, just to go through the process again. Delightful. Thank you for reminding me (kicking my rear) on this item.

Net result is I will have pay cash for a 2-level ADR, or hybrid ADR-Fusion. Loss of Reflex, Drug Use Increase, No Exercise Capacity, ... and more loss of physical capability and will lead to other complications / restrictions and will push me into surgery. Waiting too long may force one (me) into fusion because the facets will be further damaged beyond normal aging due to loss in disc height, ... trade-offs.

Slackwater

[Slackwater]

Originally posted by Slackwater:
Cigna saw there was an auto-accident & lawsuit. Surgeons may think symptoms are exaggerated, see "Validity of Self-Reported History in Patients with Back and Neck Pain after Motor-Vehicle Accidents (MVA) , NASS 2007 Annual Mtg.

Above web link led to a blank page where text was deleted. The abstract, not the full article, of Dr. Carragee's article in <span class="ev_code_PURPLE">The Spine Journal, Volume 8, Issue 2, March-April 2008, Pages 311-319</span> is below, <UL TYPE=SQUARE>Validity of self-reported history in patients with acute back or neck pain after motor vehicle accidents[/list]===================================

Well, ..., I know my body ages. Aging means my discs are expected to degenerate (dehydrate) like anyone else's discs and yes I probably had some level of osteophyte growth. However, my foot was not tingling & my legs were not twitching with spasms requiring muscle relaxants and vicodin before the SUV rear-ended me. I may not like to read what all the surgeons have to write, but I want to read it anyway.

[kimmers]

Add me on to the list of those denied ADR.
Blue Cross of Ca denied once and then appealed. Yesterday, got notice they upheld the denial, reason, "investigational".
Have qualified for IMR with Dept of Managed Health Care. Who said, "I have not yet begun to fight"?
I will get this surgery at L4/5 paid for.

Kimmers