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  #1  
Old 02-10-2014, 12:50 PM
Kelly4ADR's Avatar
Kelly4ADR Kelly4ADR is offline
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Default Cervical two level: Aetna

I am in need of a two level cervical ADR. I have Aetna PPO out of Lexington, KY. I live near Seattle, WA.

I haven't received a denial from Aetna yet, but I am anticipating one.


Does anyone have experience with A TWO LEVEL CERVICAL ADR APPROVAL WITH AETNA?


Any information about the appeal process would be very much appreciated.


Thank you!!!
__________________
2004 MRI -cervical bone spur causing pain
2011 MRI -5 bulging discs at C3-7: Recommended C5-6 and C6-7 for a two level fusion, I said no thanks.
2014 MRI -progressive compression C5-7.
MRI 6/5/14- Ruptured L4-5, bulge at L2-3 and L5-S1 Dr recommends discectomy of L4-5 but won't do surgery until cervical is stable
8/2014- 8 months/3 rounds of appeals, Aetna denies 2 level cervical ADR
2 level ADR w/ mobi-c C5-7 Jan 7, 2015
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  #2  
Old 02-25-2014, 12:22 AM
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Kelly4ADR Kelly4ADR is offline
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Posts: 259
Default Phase one: Aetna Denied

I am tracking my insurance progress on this thread to hopefully give some insight to others...

I saw Dr. Wohns at Neospine Clinic in Puyallup, WA on Feb 14, 2014

He confirmed that I need a two level disc surgery at C5-6 and C6-7. He did not recommend fusion but recommended ADR. Explained how mobi-c is now FDA approved for two level cervical. Then I said "lets talk about insurance..."

His response was that his clinic was having a really good track record of getting ADR's paid by insurance. I asked him about a two level... He said that is a little harder but they are seeing it be approved. Worse case, Aetna will pay for one level, I will pay out of pocket for the second, but it would be under 15K.

Feb 14, the day of my apt was a Friday. The following Monday their office was closed due to Presidents day. On Tuesday the 18th, his office put in the request for the pre-auth for the two level cervical ADR.

The next day, Feb 19, Aetna requested a questionnaire be filled out by the surgeon. They filled it out and sent it back on the 20th, Thursday.

Today is the 24th, Monday. I received a call from my surgeon's office stating Aetna denied. On the voice mail she explained that they were prepared to do a peer to peer Appeal involving their surgeons. If that gets denied, she will send another appeal. I called her back to discuss, but was unable to connect with her today.

I ordered Laurie Todd's book on insurance appeals.

To be continued....
__________________
2004 MRI -cervical bone spur causing pain
2011 MRI -5 bulging discs at C3-7: Recommended C5-6 and C6-7 for a two level fusion, I said no thanks.
2014 MRI -progressive compression C5-7.
MRI 6/5/14- Ruptured L4-5, bulge at L2-3 and L5-S1 Dr recommends discectomy of L4-5 but won't do surgery until cervical is stable
8/2014- 8 months/3 rounds of appeals, Aetna denies 2 level cervical ADR
2 level ADR w/ mobi-c C5-7 Jan 7, 2015
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  #3  
Old 02-25-2014, 08:57 PM
bwink23 bwink23 is offline
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Good luck with those appeals. Be sure to reference the court case(forget which one it is) where someone had sued COBRA i believe it was for not approving a 2-level ADR procedure....they WON.
__________________
2013 - MRI and CT scan....DDD L4-S1
left side (where my pain is) interarticularis pars fracture/defect with Spondylolithesis L5 over S1 with 2MM anterior displacement

Feb. 2014 - Hybrid lumbar fusion(l5/S1), ADR(L4/L5)...2-level cervical ADR (C5/C6, C6/C7). Dr. Pablo Clavel of Quiron Hospital in Barcelona, Spain. All M6 implants (PEEK cage and plate from Medtronic at fusion level in lumbar.) SAME DAY OPERATION for both areas of the spine.
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  #4  
Old 02-27-2014, 12:04 AM
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Kelly4ADR Kelly4ADR is offline
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Thanks Bwink. It was Cigna I will include it for sure. But...ugh. I'm exhausted. Just trying to figure out who to cc at Aetna is mind blowing. "The director of who?" The board of what?" Jeesh.

If anybody out there has precedent for two level cervical ADR with Aetna, please please let me know. I don't been care if they were reimbursed after having care in Germany either. ANYTHING WILL HELP. It is practically impossible to gather this info due to HIPAA, and even if the patients agree to let me use their case I can't find out who they are because of HIPAA, and on and on.
__________________
2004 MRI -cervical bone spur causing pain
2011 MRI -5 bulging discs at C3-7: Recommended C5-6 and C6-7 for a two level fusion, I said no thanks.
2014 MRI -progressive compression C5-7.
MRI 6/5/14- Ruptured L4-5, bulge at L2-3 and L5-S1 Dr recommends discectomy of L4-5 but won't do surgery until cervical is stable
8/2014- 8 months/3 rounds of appeals, Aetna denies 2 level cervical ADR
2 level ADR w/ mobi-c C5-7 Jan 7, 2015

Last edited by Kelly4ADR; 02-27-2014 at 10:43 AM.
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  #5  
Old 03-11-2014, 04:26 PM
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Kelly4ADR Kelly4ADR is offline
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Posts: 259
Default Cervical Two Level ADR approved for Category I CPT Code

My Surgeon's staff sent my first appeal off yesterday. Included along with my appeal they sent a letter from the North American Spine Society Dated March 3, 2014. It states that NASS was sucessful in obtaining a new category 1 CPT code for two level Cervical total disc arthroplasty. They added this code and also revised the existing category III CPT code to describe three or more level arthroplasty. The change will take place on January 1, 2015. I have attached a copy if anyone needs to use this as part of their appeal.
Attached Files
File Type: pdf NASS 2 level C ADR CPT CODE.pdf (712.5 KB, 24 views)
__________________
2004 MRI -cervical bone spur causing pain
2011 MRI -5 bulging discs at C3-7: Recommended C5-6 and C6-7 for a two level fusion, I said no thanks.
2014 MRI -progressive compression C5-7.
MRI 6/5/14- Ruptured L4-5, bulge at L2-3 and L5-S1 Dr recommends discectomy of L4-5 but won't do surgery until cervical is stable
8/2014- 8 months/3 rounds of appeals, Aetna denies 2 level cervical ADR
2 level ADR w/ mobi-c C5-7 Jan 7, 2015
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  #6  
Old 03-24-2014, 11:03 AM
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Kelly4ADR Kelly4ADR is offline
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Posts: 259
Default Update: There are no new updates

I called my spine clinic about 10 days after she said she sent the appeal to Aetna. She called me back the next day, saying that she called Aetna to follow up and they said "we never received it". She faxed it to them again that day and said she will be checking with them every few days. So I will be calling her every few days to check that she checked with them. Because I have nothing better to do and this is really fun for me. Not.
__________________
2004 MRI -cervical bone spur causing pain
2011 MRI -5 bulging discs at C3-7: Recommended C5-6 and C6-7 for a two level fusion, I said no thanks.
2014 MRI -progressive compression C5-7.
MRI 6/5/14- Ruptured L4-5, bulge at L2-3 and L5-S1 Dr recommends discectomy of L4-5 but won't do surgery until cervical is stable
8/2014- 8 months/3 rounds of appeals, Aetna denies 2 level cervical ADR
2 level ADR w/ mobi-c C5-7 Jan 7, 2015
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  #7  
Old 04-08-2014, 12:38 AM
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Kelly4ADR Kelly4ADR is offline
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Join Date: Jan 2014
Posts: 259
Default ADR companies will help you with appeal

Still waiting to hear from Aetna regarding the first appeal that my surgeon sent. Although they did send me a postcard stating that they received it and will be reviewing it. I did, however, contact my spine clinic and asked them what's next if Aetna denies the appeal. She gave me the number to a business in CA that deals with appeal help, so I called there and left a message. The next day I got a call from my spine clinic. Apparently the rep from the business in CA that she referred me to doesn't help patients, only businesses. The rep called her and told her to have me stop calling. then she said they were contacting LDR to see who could help me. An LDR rep gave them a number for me to call... The LDR reimbursement and appeals dept. (LDR makes mobi-c, the cervical device I am waiting for). Of course they have a dept such as this, they want to sell their product. so, I called them! And... She wouldn't talk with me because they have to work through the surgeons office. So... I called the spine clinic back, and asked her to send the release to me so I could sign so she could talk with them. She sent the release and I called LDR back and she talked to me this time, explaining if Aetna denies the request that has been submitted, then LDR can send an appeal on behalf of my surgeon. If that is denied then they will send one on my behalf. They already have an appeal packet ready to go. I would just plug in my personal info and sign. This is a relief to know since I have already started an appeal and it is very taxing. It is a lot of info to try to gather and organize. I know it seems as if I'm talking a lot about nothing, but maybe these two things can be helpful to someone:

1) If you need to appeal your insurance decision, call the company of the prosthetic you are seeking. They can probably help you.

2) if at first you don't succeed, try...try (or call...call ) again. We are our best advocates.
__________________
2004 MRI -cervical bone spur causing pain
2011 MRI -5 bulging discs at C3-7: Recommended C5-6 and C6-7 for a two level fusion, I said no thanks.
2014 MRI -progressive compression C5-7.
MRI 6/5/14- Ruptured L4-5, bulge at L2-3 and L5-S1 Dr recommends discectomy of L4-5 but won't do surgery until cervical is stable
8/2014- 8 months/3 rounds of appeals, Aetna denies 2 level cervical ADR
2 level ADR w/ mobi-c C5-7 Jan 7, 2015
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  #8  
Old 04-08-2014, 08:56 AM
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jss jss is offline
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Kelly,

Good luck. We're all holding our breath.

BTW the same thing happened to me. I sent in the original claim and waited weeks without hearing anything; only to have BCBS-TX claim to have not received it.

Good luck!

Jeff
__________________
C4/5 - ACDF in 2000
C5/6 - ACDF in 2002
C3/4 & C6/7 - M6 ADR, Nov 2009, Barcelona
Conceded defeat to a manifestly disingenuous BCBS-TX in my quest for reimbursement, Jan 2011
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  #9  
Old 04-08-2014, 08:28 PM
Jerry5 Jerry5 is offline
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Join Date: May 2013
Posts: 363
Default Adr

Kelly,
I am with you, I have been going after this for months, I just submitted my claim to BCBS, International, and sent them the information from the german hospital (ONZ), and my most recent MRI.
I have had to call them a couple of times.

The first, I had submitted the wrong type of claim, and so she was nice enough to process this on the phone, and gave me a new claim number.
Then I had to call a few business days later, and they said they needed the above information.
She was surprised I had all this, called the following day, and another agent, and she said they had reviewed or had started to process this information.

From what I know, this can take a business week.

For all the effort they put into making you take tests, and use conservative methods, (I am still getting requests for information, about the last surgery, the discectomy) and all the agents you have to spend time with, they would be better off, just paying for the surgery, the ADR, and be done with it.

There have been failures, but these have been documented, and the later generation discs, namely, the M6, has had very good results.

You are right, No One will look out for your interests, they will do what they can to keep you from this treatment.

One other point, thank you for the information, getting the Spinal Kinetics involved, I have contacted them once, about timing, but not about help appealing.
I have emailed the FDA also, she came back and said the M6 is 'approved' for Export Sale only, how do they figure this?
__________________
Jerry, Somewhere Ohio

L2-3 herniation, two days before Thanksgiving, 2012, Discectomy/Laminectomy, 3/13 Numbness in the right leg, lateral femoral, gone, July 10, 2014 L45 M6 ADR, July 15 PLIF L5-S1, Not able to access L51 Anterior.

Last edited by Jerry5; 04-08-2014 at 08:42 PM. Reason: add'l info
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  #10  
Old 04-11-2014, 10:22 AM
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Kelly4ADR Kelly4ADR is offline
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Join Date: Jan 2014
Posts: 259
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Jerry,

Hang in there! It's frustrating, I know. I have dealt with insurance companies for 15 years with my massage business. In the last two years or so we have been receiving a crazy high number of denials for very stupid reasons for massage treatment. This is not an expensive treatment in the insurance business, yet they don't even want to pay for that these days, let alone an expensive surgery.

What I have learned is they bank on those people who won't try to fight it, those who don't know they can, or those who are in too much pain to wait it out. Fortunately, I am not in any of those situations.

For me, it would be different if the denial was for a valid reason. If they deny due to "experimental/investigational" and it actually was, I could trust that they don't want to pay for treatment that might harm people. But, when they use this blanket statement as a first level automatic rebound, full well knowing there is plenty of proof otherwise, it makes me mad. not to mention the fact that my spine clinic has had this exact same surgery paid by my insurance four times before? I'm willing to jump through hoops just for the principle of it all.

I would recommend picking a day of the week to deal with insurance issues, whether it be appeal prep, phone calls, research, etc. make sure you check with insurance once a week if you are waiting on something, otherwise you could wait a month to call them and hear the infamous "we never got it". Then, the rest of the week, live your life. Take care of yourself and remember to do small things to help your pain, etc. it is so easy to fall into the trap of focusing so much time and energy on being mad at insurance and waiting for surgery to cure you, that we forget to live our life. I had to consciously decide not to let this consume me.

You said you saw a VA MD? What branch of the service/era were you in? Have you tried any other VA resources to help you with the process? My dad and husband are both Marines, veterans of Vietnam (dad) and Gulf War (husband). The VA has come a long way providing resources to veterans, so much so that my dad is seeking services that he swore he never would because they have actually been helpful.
__________________
2004 MRI -cervical bone spur causing pain
2011 MRI -5 bulging discs at C3-7: Recommended C5-6 and C6-7 for a two level fusion, I said no thanks.
2014 MRI -progressive compression C5-7.
MRI 6/5/14- Ruptured L4-5, bulge at L2-3 and L5-S1 Dr recommends discectomy of L4-5 but won't do surgery until cervical is stable
8/2014- 8 months/3 rounds of appeals, Aetna denies 2 level cervical ADR
2 level ADR w/ mobi-c C5-7 Jan 7, 2015
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