Introduction & insurance questions

[lizey p.]

Hi, everyone –

I can’t say I’m new to the boards since I’ve been lurking here for over a year, but I haven’t yet made my introductory post so here goes.

My low back pain started when I was 18 or 19 and gradually got worse over time. I’m 38 now. In 2000 I was diagnosed with DDD and began a long list of conservative treatments (physical therapy, etc.). In 2003 a low back pain episode that started in October kept getting worse until New Year’s Day 2004 when a sneeze I couldn’t suppress finally caused L4-5 and L5-S1 to rupture. (The MRI showed the extruded disc material at L4-5 measured 16mm x 9mm and had migrated 2cm up my spine. Mark ******* would later refer to it as “the mother of all extrusions.")

In the past three years, I’ve had three disc ruptures, multiple bulges, two spinal surgeries, a dozen or so spinal epidurals and nerve block injections, half a dozen MRIs, two discograms, countless x-rays, and what feels like a thousand hours of physical therapy. I have permanent nerve damage in my left leg and foot. This winter, ten weeks after my second back surgery, I was hospitalized for a week after a massive blood clot (DVT) formed in my right leg, starting at my pelvis and continuing all the way down to my ankle, the thigh portion of which then broke off and traveled to my lungs, causing severe bilateral pulmonary emboli (blood clot material clogging nearly every vessel in my lungs on both sides). The ER doctor said I was lucky to live through it.

I’ve been researching artificial disc replacement since 2004. It’s been a long and painful road, but I’ve gone through my decision-making process my way and am now on Dr. Bertagnoli’s docket for this spring. Whether I’ll need two or three levels is still TBD. All I need are fresh MRIs and x-rays. I considered having my surgery in the US when my spinal surgeon (Zucherman, here in SF) told me Synthes gave him permission to do two-level ProDisc replacements off-label but A) I may need 3 levels, which Zucherman has never done and B) I want to go to the most experienced surgeon I can find, and the one who’s done more multi-level ProDisc replacements than anyone else is Bertagnoli, who by all accounts is an excellent choice.

I’m lucky to have Aetna health insurance and to work for a company that funds its own health plan. This means that ultimately, my employer can make decisions to cover claims that Aetna may deny. I’ve spoken with Aetna reps via email and on the phone and have gleaned the following re: our particular plan:

1) It will cover only emergency surgery, overseas (as opposed to scheduled surgery, such as ADR)
2)It will cover only overseas procedures that are also available in the US. In other words, since multi-level ProDisc replacement isn’t available in the US, they won’t cover my having this procedure in Germany.

I can argue against #2 since there are people on these boards who’ve gotten 2-level ProDisc replacements (albeit with the 2nd disc off-label) in the US covered by Aetna, though of course each plan is different.

Here are my questions:

1)Is it worth going toe-to-toe with Aetna through the two-level appeals process, on the slim off-chance I could convince them to pay for a multi-level procedure overseas? Has anyone out there been through this? If yes, would you be willing to share your approval letters with me so I can reference them in my appeals?

2)Is there anyone out there who works for a company with a self-funded health insurance plan who’s convinced their employer to override their plan’s denial of an ADR claim? I realize this experience will vary by employer, but I’d love to hear anything anyone has to offer before I try to tackle this myself.

I’m happy to take replies as PMs.

Thanks to all of you for everything you share on these boards. Like so many others, I’ve learned an enormous amount from you and deeply appreciate the resource these boards have become.

Eliza

[LBP]

Eliza,
I cant remember the guys name but there was someone in San Diego that worked for a company that was self insured. I think a lot of it has to do with the position you hold, how much they like you, how long you've been with them etc.

I would be surprised if Aetna didn't approve your multi level. Have you talked to Dr.Delamarter's office in LA? Has he done 3 levels?

[lizey p.]

Hi LBP --

I know Delamarter is great, though even if he has done a 3-level I'd still choose Bertagnoli. After thinking about it for the past couple of years, I arrived at the conclusion that I'm not willing to have this surgery with anyone other than the most experienced multi-level ProDisc replacement surgeon I can find, and that's Bertagnoli.

I'm lucky in that I have an experienced ADR surgeon here in SF (Zucherman of St. Mary's Spine Center) who can provide my aftercare. He's also helping me prep, deal with insurance, etc. so he's a great resource. It hadn't occurred to me to use Delamarter the same way, but that's a good suggestion. Thanks.

I hope the person you referred to who works for a company w/self-funded insurance sees my post... I think my company will be supportive, but it would be helpful to connect with someone who's been through the process before I dive in.

Thanks again for your reply.

Eliza