Any Medicare Prodisc-C approvals?

[KarlMark]

Has anyone successfully had Medicare pay for a Prodisc-C surgery? I'm too young to be retired, but I'm disabled and pretty new to Medicare. My doctor has recommended that I get a Prodisc-C ADR, and if the surgery is successful, maybe I could go back to work.

I'm used to insurance companies pre-approving surgeries, and my understanding is that Medicare doesn't pre-approve anything. I could have the surgery and get stuck with the bill. Yikes!

I'm a little squeamish about going ahead with the surgery given how many insurance companies are hostile to ADRs. (Even Medicare does not cover lumbar ADRs in people over 60. See: US Medicare (Synthes) Coverage....)

So how has it gone for others? Has Medicare covered a Prodisc-C ADR for you, or not? If so, please let me know. Thanks.

-Karl

[Jstuckey]

As a Medicare provider of therapy services, we (as the provider) are required to know what is covered under Medicare. The patient signs an "ABN" - Advance Beneficiary Notice - when we have confirmed that something will not be covered. We are required to write in the dollar amount and the patient signs that they understand it will not be covered by Medicare and they will be responsible. If we fail to do that, they are not responsible for the bill. I'm not sure how surgery works, but Medicare is pretty standard for procedures like this. Talk with your provider - they are the ones who need to provide you with information about coverage and whether you will be held responsible for any bills. Hope this helps!

[KarlMark]

Joey Sue, thanks for the information. I have tried talking with my doctor's staff, but since there is also a hospital involved, it's difficult to get straight answers.

So far, here is what I have discovered by searching for some documents on www.cms.gov. A few years ago, Medicare issued a National Coverage Determination (NCD) that *lumbar* ADRs would not be paid for by Medicare in patients older than 60 anywhere in the U.S. They left it up to local payment contractors to decide about patients under 60. (There are more details about this in other postings on adrsupport.org that you can find by searching.)

These "local payment contractors" are businesses that Medicare hires to handle payment processing for Medicare services. One of these companies is Noridian Administrative Services. They do payment processing for nine states: Alaska, Arizona, Oregon, Washington, Montana, North Dakota, South Dakota, Utah, and Wyoming. Even though the NCD only referred to lumbar ADRs in patients above 60, Noridian took a rather liberal interpretation and issued a Local Coverage Directive (LCD) indicating that they won't pay for ANY ADR (cervical or lumbar), even for those under age 60. So in these states, it seems that getting an ADR paid for by Medicare would be nearly impossible.

Here is the Noridian LCD for Arizona, but there are near-identical documents posted for the other states listed above:

http://www.cms.gov/mcd/viewlcd.asp?l...ion=9&show=all

The payment contractor for my state is Palmetto GBA. They have issued an LCD that seems to just reiterate the Medicare NCD. So it seems possible that Medicare might cover a cervical ADR in my state.

Joey Sue, now I'm going to follow your lead and look into Advance Beneficiary Notices. I've done just enough digging to find out that there are different kinds, so what happens in a therapy setting might be different than what occurs in a hospital. I'll report back what I find.

In the meantime, I'm still interested in hearing from other folks... Has Medicare covered a Prodisc-C ADR for you, or not? If so, please let me know. Thanks.

-Karl