Has anyone been covered by Health Net or Blue Cross of California?

Hi! My name is Mackenzie and I had an artificial disc operation about 4 months ago and doing great. I had L5-L6, L6-S1 (I have an extra vertebrae) done with the Prodisc. I ahve had horrible problems with getting coverage from my insurance companies. I have tried through Blue Cross of California-PPO and Health Net of California-HMO-and no luck with either. But as I read on the forum I have discovered people that have had both insurance companies, and HAVE HAD THEIR SURGERIES COVERED. Why am I and others not getting coverage while others are? I think that we need to start making a bigger deal about this. Do you all know that this is discriminatory and they can't do that-it's called "bad faith"?
If anyone has had these insurance company's cover their operations can they contact me immediately? Thanks!
Mackenzie
kenzwaters

[luvmysibe]

Hi Mackenzie,
I have spoken with my orthopaedic surgeon and nurse case manager regarding coverage by Blue Cross of California. Neither of them knows of a case that BC of CA has approved. There are many forms of BC, but to their knowledge BC of CA has not approved ADR especially for more than one level and/or anything other than the Charite. This probably isn't what you are hoping to hear, however, it's all the information I have obtained thus far. Good luck!

Hi Mckenzie,
I also have Blue Cross of California and while I have talked with them, they danced arount the issue, talking about "medical necessity" etc,etc, basically the run around.
Then I came across a blanket statement on the internet with BC of Calif saying they will not cover "any" requests for ADR reimbursement. Some folks are probably getting some reimbursement for things like, for instance, if they have a fusion at one lumbar level (which they will cover) and at the same operation have an ADR placed at another lumber level. It is just the ADR device and coding for ADR surgical fee that they don't cover in that instance, but will cover hospitalization costs OR time etc, but I would be interest in joining anyone preparing for a class action lawsuit. I am an MD (Diagnostic Radioligist" and in my view they are practicing medicine without a license.
I am soon going to have a 2 (possibly 3) level ADR procedure here in Thailand where I have found an Excellant orthopedic surgeon who had done over 100 ADR discs, experienced, knowlwdeable and with a team approach with the local Medical University. I calculated that with the low cost of medical care in Thailand compared to the US, I can have the procedure and it will be less than if I pay my deductable ($5000) and have Blue Cross cover 70% of the rest.
Robert

[Juli]

Hello Robert,

How much are they quoting you over there for a two level and do you have a link or contactinfo?

I have a friend that is trying to figure out a way to afford the surgery, he does not have any insurance and is probably not a good candidate for clinical trials.

Thanks,

Hi Julie,
For a 2 level procedure, the cost will be about 800,000 Thai baht, which is about $20,000 US at the current exchange rate of about 40 Baht/Dollar. That is assuming an uncomplicated outcome and about a 4 day hospital stay.
The hospital web site is http://www.bnhhospital.com
Dr. Wicharns email is wicharn@thaispinecenter.com
The Spine Center is http://www.thaispinecenter.com It is written mainly in Thai so it is not so helpful unless you know or have a friend that can read Thai.
Dr. Wicharns' CV can be viewed at http://www.thaispinecenter.com//cv-eng.asp
He has been very responsive to my e-mails perhaps in part because I am an MD but I am sure he would respond kindly to anyone.
I know he is very skilled, the local J and J representative who promotes the Charite disc, chose him over all the Asian Surgeons she encounters in her promotion and working with Surgeons doing ADR procedures, saying he is the best, he did a 2 level replacement on her, I visited her 2 days post op and she was pain free, walking and sitting and flexing without pain in her back. Only pain was at the surgical site.
My own procedure is on Feb 3rd 06, and I will have 2 (or possibly 3 level, pending the outcome of an L5-S1 Discogram) discs replaced.
He is trained in doing Charite and Prodisc, and he seems to be having excellant results, the J & J rep relayed that information to me. Another patient who had cervical surgery praised him as well (I was waiting to see him for my first appointment).
Good luck for your friend, life with back pain should not be allowed, the US medical system is slowly sinking, getting so costly and so complicated to deal with the Doctor/patient ratio rapidly diminishing. I see it every day.
Robert

I'm confused Robert

First you mentioned your multi level ADR in Thailand would cost less than your BCCA 5K deductible but then later suggested the cost of a 2 level would be about 20K US dollars????

[Laura C]

Mackenzie


I have BC of California and they denied me twice. Our insurance is thru The Directors Guild and they have the last say - I took it before the board of trustees. Is your insurance thru your employer? However, I would keep fighting them to pay. I am having a fusion and 2 ADR on Jan 11th - my case is a bit unusual as I am missing a facet joint (either broken or never had one) at L5-S1 level that created all kinds of havoc.

Good Luck and KEEP FIGHTING....

SSS,
I will repeat, the procedure in Thailand is 800,000 Thai Baht, that translates into US Dollars to 20,000 total dollars.
IF BCCA covers my procedure, I have to cover my deductable ($5,000) and then I pay 30% of the remainder of the costs, assuming I go to a BCCA contracted facility and physician (otherwise they only cover 50%).
The procedure in the area where I am is probably in the neighborhood of $60,000 I would guess, including costs of hospitalization including the costs of the devices, Surgeons Fee, etc. If I pay 5,000 deductable that leaves, $55,000, and 30% of that is $16,500, that plus the deductable is $21,500. That is more than the total out of pocket costs in Thailand by about $1500.
That is how it is. BUT Blue cross covers no ADR procedures. So I can choose to pay $60,000 out of pocket in the my area, search for cheaper rates elsewhere in the US or go elsewhere to have the procedure, as many people are doing, going to Europe, Singapore, Australia, and myself choosing Thailand.
I hope this clarifies things.
Robert

robertmd
may i ask why you are choosing thailand?
when germany seems to be the ticket.
do you know something we dont ?
chuck

chasswen,

I must admit I really don't know much about Germany except through my internet searching and this site, I have not personally gone there or had my studies reviewed there.
I do know that health care in Thailand is very good, I come here often, and enjoy the people and country, and that it is relatively inexpensive. There was a clip on 60 minutes featuring 2 patients who come to Asia , aone a lady who went to India, and another was a guy who had triple coronary bypass surgery at a private hospital called Bumrungrad Hospital which is the only hospital in Asia that is JCAH approved.
I probably would have searched more to include Germany but I found this Orthopedic surgeon who is adept at doing ADR and that patients really praised him and the fact that he was so responsive to my needs.
I think he is every bit as experienced as other good surgeons doing ADR. And skilled and responsive. I ended my search after I met with him.
Robert