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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 11-08-2007, 05:40 PM
mgs32 mgs32 is offline
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Hi All,

This is my first post. I just found this site recently and it has been very informative so far! A little background... I am a 24 yo female. I've been healthy and very active my whole life, until recently. I've been having neck and right arm/hand pain for about a year and a half right now. No accident, just started noticing bad pain in arm/hand while typing and shoulder while running, and then the neck pain began. I've tried two rounds of physical therapy, lots of medication, and have stopped most of my normal daily activities. Two MRIs have shown disc herniation at C5-6, and DDD at C6-7. My neurosurgeon has recommended removing both discs and either having a fusion, 2 artificial discs (though this would require some special approval since 2 discs is not FDA approved??), or a hybrid (1 fusion, 1 artificial disc).

So, to my question... I'm wondering at what point you all contacted your insurance company regarding coverage for an artificial disc. My neurosurgeon never mentioned any concern over insurance with me, so until I saw this site, I had never even thought about it. Did your doctors tell you to contact your insurance company, or is this just something I should know to do on my own? Clearly I'm new to this, so any help would be greatly appreciated. Thanks!
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25 y/o female
Pain in neck, shoulder, arm, hand since Spring '06
MRI showed herniated disc at C5-6, DDD at C6-7
Doctor has recommended one level ProDisc-C ADR

ProDisc-C March 18,2008
Felt good for a few months, now pain in right side of head, shoulder, neck, arm, hand
MRIs and CT Scan suggest problem with facet joints
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Old 11-08-2007, 07:19 PM
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Terry Terry is offline
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Join Date: Oct 2006
Posts: 1,210
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MGS32:

I contacted my insurance company ahead of time and the surgeon in Michigan who originally wanted to do the lumbar ADR surgery also contacted them to get pre-approval. The surgery was denied and he wanted $55,000 to do a two level lumbar ADR. I went to Germany instead and got a two level ADR Cervical and two level ADR lumbar for $61,000. My insurance company denied it three times and then ultimately paid for it. I have great coverage and am happy with my company though they have been the exception vs. many who post here. I would humbly suggest you get your doctor to advocate for you and you should also be contacting them. Good-luck to you and welcome to the forum.

Terry Newton
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1980 ruptured L4-L5
1988 ruptured SI-L5
1990 ruptured C5-C6
1994 ruptured C6-C7
1995 Hemi-Laminectomy C5-C6, C6-C7 Mayo Clinic
Bicycle Accident 2004
MRI, EMG, Facet Injections, Epidural Blocks, Lumbar Discogram.
Stenum Hospital Surgery November 4, 2006
Prestige Disc C5-C6, C6-C7
Maverick Disc S1-L5, L4-L5
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  #3  
Old 11-08-2007, 08:32 PM
LBP LBP is offline
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Join Date: Aug 2005
Posts: 446
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When you find yourself ready to make a decision about whether to have surgery, which surgeon, what procedure etc....and you give the surgeon the green light to go ahead...the dr's office usually files a preauthorization request with your insurance company. Pre authorization is usually still not a guarantee that they will actually pay/cover the procedure but it's a good indicater. If you get approved..great, it's when they deny you that you must read everything carefully to make sure you file appeals within the appropriate timeframes.

You can try to get a 2 level approved even if the FDA has only approved it for one level. Just depends on your insurance company.


Good luck.
__________________
Injured 9/01
Annular tears L4/5 & L5/S1
denied adr by insurance for 2 level charite as well as hybrid fusion at L5/S1 with Charite at L4/5.

New ins paid for 2 level lumbar prodisc surgery on 4/7/08 (at age 39) with Dr. Westerlund, at Core Orthop
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