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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 03-09-2015, 11:35 AM
luckyshot luckyshot is offline
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Default thinking about trying to stick it to aetna

been awhile since I posted. I had two level prodisc l at texas back institute on 8-19-13. paid 63K out of pocket. no help from AETNA. have now rode the appeals system to the last denial letter.

made a couple appointments with an attorney. the attorney's findings were that no cases have went to trial in my us court district for 2 level adr. According to him, he can find any court documents, but he cant see anything that may have been settled out of court.

I'm also assuming that anything settled out of court more than likely had a non-disclosure agreement attached. Does anybody have any advice on where to go from here? Is it worth trying? I have less than a week to make up my mind. Thanks
__________________
L4-L5 and L5-S1 broad disc protrusions
superimposed central disc extrusions, stenosis..
Entrapment of L5 nerve roots.

Looking for a way to do two level ADR in the US through Aetna.
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  #2  
Old 03-09-2015, 11:44 AM
luckyshot luckyshot is offline
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on a brighter note-
I was 27 when I had surgery, 29 now. Walked farther the day after surgery than I had in months. My boy turned 1 while I was in texas, I could barely pick him up before surgery- couldn't get him out of the crib. now he's 2 and a half, and I can do whatever I want with him. I ride 4-wheelers again, i shovel snow, i bust wood, i run, i hike miles in the snow, im pulling back my 73lb bow and dragging deer out of the woods. I do whatever i want and never take so much as a baby asprin.......

all because of an "experimental surgery". I thank God for getting me through it, my family for support, and the folks at TBI for doing it right.
__________________
L4-L5 and L5-S1 broad disc protrusions
superimposed central disc extrusions, stenosis..
Entrapment of L5 nerve roots.

Looking for a way to do two level ADR in the US through Aetna.
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  #3  
Old 03-09-2015, 04:24 PM
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jss jss is offline
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Lucky,

Congratulations on your excellent outcome! Here's hoping that you luck (and mine too) continues to be good.

I don't know if this will help you or your attorney, but here is a link to an article where Cigna was court ordered to cover a two level cervical ADR.

Good luck!
__________________
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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  #4  
Old 03-09-2015, 11:39 PM
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Cynlite Cynlite is offline
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Default Cigna Ruling

Jss, Thank you for posting the article and ruling. I hope it helps all of us who are fighting to change coverage for this surgery!

I am seriously considering having the surgery in Germany and wonder if Cigna would use that as another reason to not cover it after the fact. I already know I'll have an up hill battle to get the surgery covered here in the U.S. I can't imagine waiting another year and putting off the surgery just to have coverage turned down.

I hope you had a positive outcome from your surgery in Barcelona! Would love to know how that M6-C is working out for you. Was your surgeon Dr. Clavel?
__________________
2006: epidural shots did nothing; 2 surgeons recommended 2 level fusion, I declined.
2007 - 2010 4 foraminotomy and cord decompression cervical surgeries and 2 endoscopic discectomy T7-T8 surgeries; total 6 with Dr. Jho (Pittsburgh,PA) My C6/C7 autofused around 2009.
2013 - 2015: epidurals 3 times (again did nothing) and 4 Radiofrequency ablation (or RFA) procedures.
2016 more RFAs, hit the 10 year mark of this insanity and pain, 3 level M6-C ADR with Dr. Clavel May 19, 2016
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  #5  
Old 03-11-2015, 08:55 AM
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jss jss is offline
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Cynlite, if possible your health insurance carrier would use your hair color to deny payment for ADR. Yes, you can bet they'll try and use the fact that it was not in the US to deny.

My M6's are still doing great. In July I'll be cleared of all restrictions from a hip resurfacing surgery I had in January. I'll be ready to start training for my next century bike race, marathon and Ironman.

Good luck!
__________________
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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  #6  
Old 03-11-2015, 12:31 PM
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Cynlite Cynlite is offline
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Wow, those are amazing goals! I'm so incredibly happy for you. It's just amazing. It's people like you that are giving me hope that I might be able to reclaim some of my life back. To be active and athletic again would just be a dream come true. I know it may not be in my future because I've been suffering for nine years but, I can hope!

I am going to speak to Dr. Bierstedt in Germany this afternoon. I'm pretty excited to get the ball rolling. After that, I'm trying to decide if it makes sense to contact Dr. Clavel. Did you have any PT as part of your recovery process in Spain? That is how they are handling it in Germany so, the total time in the hospital will be 6 days and then I would be moved to a rehab facility for a week. I kind of like the set up because it makes me feel more confident that the surgeons will be there in case something goes wrong after the implant surgery.

I had an ACL reconstruction on my knee 25 years ago. The proper muscle development after the surgery impacted the pain and healing process. PT didn't cut it for me then but, the surgeon kept telling me everything was fine. I was still in pain. I took Tai Chi a year after the surgery (for six weeks) and suffered through it having to ice afterwards every time but, damn if it didn't get all the muscles in my leg and around my knee firing again. I skied a lot on that leg until my neck gave out! Keep Tai Chi in mind for your hip.

I'm going to see the U.S. surgeon on the 23rd but, I'm just not holding my breath that the insurance company will play nice. (Loved your comment BTW.) I'd like to speak to at least two surgeons to get their opinions on what they think needs to be done.

Any feedback you can give me about Dr. Clavel would be greatly appreciated! Getting opinions from three surgeons might be better. Hopefully, they will all agree on what's going on....hahahahhaha
__________________
2006: epidural shots did nothing; 2 surgeons recommended 2 level fusion, I declined.
2007 - 2010 4 foraminotomy and cord decompression cervical surgeries and 2 endoscopic discectomy T7-T8 surgeries; total 6 with Dr. Jho (Pittsburgh,PA) My C6/C7 autofused around 2009.
2013 - 2015: epidurals 3 times (again did nothing) and 4 Radiofrequency ablation (or RFA) procedures.
2016 more RFAs, hit the 10 year mark of this insanity and pain, 3 level M6-C ADR with Dr. Clavel May 19, 2016
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  #7  
Old 03-11-2015, 03:40 PM
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jss jss is offline
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Cynlite,

In five years the M6's have survived four marathons, one Ironman, and probably a dozen or so 100 mile races/rides. I always assumed that it would be spine problems that sidelined me; not a hip. We'll see. I'm doing the home therapy the hip guy prescribed. I'll keep Tai Chi in mind. Right now I'm ecstatic that I can finally tie my shoe again! I've heard that knee surgery is orders of magnitude more difficult to recovery from than the hip. So you give me hope.

I was one of Clavel's early international patients. Back then he didn't prescribe therapy for cervical patients like he does now. I don't know if it's beneficial or not. I do know that we far more enjoyed walking around Barcelona than we would have me sitting in therapy. Had there been a problem we had ready access to Clavel; or more likely one of his associates.

I'm convinced that more opinions is usually a good thing. If they converge it will give you confidence that you're moving in the right direction. Clavel is an endurance athlete also; we've even done one of the same races, though not at the same time. So he certainly understands someone wanting to get back out there. The only caution I'd give you specifically about Spain is that very few people speak English, and chivalry didn't make it south of the Pyrenees. You will feel more 'at home' in Germany and you will have a great outcome if you pick an experienced surgeon that produces a steady stream of good outcomes.

Good luck!
__________________
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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  #8  
Old 03-11-2015, 05:01 PM
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Cynlite Cynlite is offline
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Posts: 666
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All good advice! Thanks so much.

Wow, those M6's are really getting a work out in your body Also, really good to know that they can handle it! If I ever get set free from this cage I've been in, I'll be scheduling the next ski trip as soon as I'm physically able. I was quite addicted to it and planned on skiing until I was a very old lady. My Mom told me I needed to stop doing that kind of stuff at 40 but, that certainly wasn't in my plans. Now, I'm over 50 and dying to get out and travel and play. I live vicariously through so many friends of mine on Facebook right now boo hoo.

I just read up on your hip surgery and wanted to share with you something. My gate has gotten really funky because of my neck issues. In the last three months, that knee of mine has been acting up and I'm sure it's because I'm walking weird on it. It's so important to have all the muscles working in concert with each other. I try to keep my posture correct but, my hips are also wobbly now so both hurt along with my knee, head and neck ...damn, I'm a train wreck. Anyway, I think it was a good call to not do the hip replacement. I sure hope it works out for you so you can continue conquering the world.

I sure wish I had known about ADR back when I had my surgeries. I was in so much pain and trying hard to avoid a fusion....oh well, hindsight sigh ...
__________________
2006: epidural shots did nothing; 2 surgeons recommended 2 level fusion, I declined.
2007 - 2010 4 foraminotomy and cord decompression cervical surgeries and 2 endoscopic discectomy T7-T8 surgeries; total 6 with Dr. Jho (Pittsburgh,PA) My C6/C7 autofused around 2009.
2013 - 2015: epidurals 3 times (again did nothing) and 4 Radiofrequency ablation (or RFA) procedures.
2016 more RFAs, hit the 10 year mark of this insanity and pain, 3 level M6-C ADR with Dr. Clavel May 19, 2016
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