Insurance Coverage -- Midwest

[Dave]

It seems a number of insurance companies are starting to cover ADR, but that most are on the east or west coast.

I live in St. Louis, and I'm facing a second level appeal. Reason for the two denials to date is the "experimental" catch-all tag. Does anyone know of insurance companies in the Midwest that have covered ADR surgery? A few local or regional examples would strengthen my argument, and may help feed a desperately needed critical mass toward widespread approvals.

Thanks in advance,

Dave

[David]

Not sure if this would help or not, but Aetna considers a one-level ADR at L4-L5 or L5-S1 medicially necessary, as does BCBS of NJ, I believe.

I, of course, have UHC in Ohio, so I have just begun the "denial process"

David

[Kat]

Hello neighbor - someone from my neck of the woods!!!

You didn't mention what insurance you have, but I have UHC and they denied my ADR. I am on my first appeal, but from what I have heard from other spineys, there are very few insurance companies paying for ADR and it really varies from state to state. Just because BCBS in NJ might cover ADR, BCBS in another state might not. The biggest reason for denial seems to be "experimental, unproven". The government really needs to step in to get some sort of standard accross the board. Good Luck!

Kat

Kat

[David]

Unfortunately true.

In my case, my particular neurosurgeon said that his office has rarely had any issues getting ADRs approved, so I am crossing my fingers.

I am hoping that somehow he is able to get UHC to cover the procedure. If not, then I will probably go out of pocket, either here in the U.S., or (more than likely) in Germany.

David

[Dave]

Kat and David, and others with insurance problems,

My insurance is GHP, (Group Health Plan), a division of Coventry Health Care, purchased through my employer.

I'm scheduled to appear at a second level appeal hearing this coming Wednesday, but the procedure is bogus, so who knows if it will matter. I've recently submitted the letter and arguments for the appeal. Below is just one paragraph from a three page diatribe. If anyone would like to see the full text, send a private message with your e-mail address and I'll get it to you. I'd be interested to have a critique and ideas to add to it.

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"It�s quite easy to predict that Total Disc Replacement will be covered in the US by all insurers, just within the next year or two, or even in a matter of months. Already, Aetna considers TDR a viable alternative to spinal fusion surgery, and is paying for it. So is Blue Cross Blue Shield of New Jersey. So is Anthem in Kentucky. So is Cigna/Connecticut General in Colorado. And BCBS of New York. And who knows how many others. How long can it be?"
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The "experimental" thing just can't last very long. Trouble is, how long can we last? I'm getting progressively worse as the weeks roll by. I wonder what the executives at these companies would do if faced with the fusion/ADR question, and it was their own back troubles that were compromising their quality of life.

And Kat, you are right on with the suggestion of regulations on stuff like this: i.e. if it's FDA approved it cannot be experimental, period. The free market often works fine, but the health care situation in the US is such an incredible mess. And who has the courage or will to fix it?

Hang in there...

Dave

[Kim]

David
In your earlier post you said that your neurosurgeon had told you that they rarely had problems getting ADR approved. I sure wish you would ask what they are doing that everyone else's physician offices are neglecting??? I mean if there is an answer to this dilemna lets find out what it is? Would you please call your drs office and find out how they are getting approvals for their surgeries? Inquiring minds and chronically painful bodies like mine are dying to know!
Thanks