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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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  #11  
Old 07-19-2007, 10:18 PM
ZorroSF ZorroSF is offline
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Thanks so much for replying. Stick with this forum a little while and someone will reply back in a similair situation that your daughter has with medicare. Every situation here, no matter how grueling and frustrating always sheds a little more knowledge on this shadowy insurance industry, regardless of provider.
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1/2006 DDD L5/S1

Prodisc St. Mary's 12/2006 not diagnosed properly pre-op and now have DDD L4/L5, facet calcification L5-S1/L4-L5, mild scoliosis and left knee pain. DDD: C3 through C6
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  #12  
Old 11-05-2007, 05:25 PM
LBP LBP is offline
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Betsy

What happened with your daughter and Medicare coverage?

after a very long wait, I just won my appeal before the administrative law judge and will hopefully be getting my checks and medicare information soon.

Did your duaghter's Medicare cover a 2 or 3 level ADR? or a hybrid ADR/fusion surgery? where did you have it done? which surgeon?

I'd also love to hear what plan your daughter elected...did she stay on the Original Medicare plan or one of the HMO/PPO privately administered Medicare approved plans?
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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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  #13  
Old 11-06-2007, 06:42 PM
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Harrison Harrison is offline
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Congrats, LBP...you've worked hard for this!
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Fell on my ***winter 2003, Canceled fusion April 6 2004
Reborn June 25th, 2004, L5-S1 ADR Charite in Boston
Founder & moderator of ADRSupport - 2004
Founder Arthroplasty Patient Foundation a 501(c)(3) - 2006
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  #14  
Old 11-06-2007, 08:59 PM
LBP LBP is offline
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Thanks Harrison.

BTW...does anyone know the ins and outs of Medicare and how to best maximize my chances of getting ADR approved????

So my question is..if you sign up with Aetna's Medicare plan, does Aetna influence the claim process with the gov't system? Is it easier to get ADR approved if I sign up with a Medicare Part C plan through Aetna vs a Medicare Part C plan through BCBS, UHC or other horrible companies?


Part A Medicare (hospital coverage)
Part B Medicare (health care coverage)
Part C Medicare (private medicare approved plans which supplement A & B and sometimes D plus other goodies for higher premiums)

Part D Medicare (prescription drugs)
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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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  #15  
Old 11-20-2007, 12:31 AM
LBP LBP is offline
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does anyone have experience with a medicare private fee for service plan? (PFFS) Did you have trouble getting drs to accept you as a patient with a PFFS medicare insurance plan?
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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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  #16  
Old 04-20-2008, 12:14 PM
epiphaknee epiphaknee is offline
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I think the following post sheds insight on getting approved by Medicare with an Aetna PFFS plan.

See:http://adrsupport.org/eve/forums/a/t...803#8871082803

This individual was approved for a two level Pro Disc with Aetna's Medicare PFFS plan, in the March or April 2008 timeframe.

As of April this individual is recovering from surgery but once they heal a little more I hope we can learn more from their experience - first hand.

In the interim we can all research if we can secure the Aetna insurance in our state, whether there is a specific enrollment period, etc. I was reviewing Aetna's site on the web and it looks like you can enroll online and/or discuss the plan with an Aetna representative M-F.

Just wanted to throw this information out there and hope others will comment. This would be a great asset for those on Medicare that need multi-level ADR. Of course, your mileage may vary.
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  #17  
Old 04-20-2008, 10:46 PM
LBP LBP is offline
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Yes, it's me. I just had a 2 level prodisc at l4/5 and l5/S1. I was pre approved under a private Medicare contracted health ins plan.I know my particular plan was offered only in limited areas, and I selected the most expensive monthly premium plan offered by this company. It's a premium over and above the monthly medicare costs but in comparison to many Cobra premiums it's much less in total.

Also, I selected one of the surgeons that was one of the investigators of the Prodisc, I have no idea if any of this matters or that it's been 7 years since I was injured. Who knows.

I was shocked when I got the approval. I didn't know what was going to happen but when I looked at the list of companies offering comprehensive medicare plans, I selected the one that I've read here has been most consistent in covering ADR.

The Aetna Medicare plan offered in my area, was a PFFS which stands for private fee for service. It allowed me to go anywhere and to anyone that accepted Medicare. there's no network/out of network or out of state issue. It's just up to the individual provider/dr to decide whether they will agree to accept me as a patient and the provider/dr can change their mind at any time I seek additional care.
__________________
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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  #18  
Old 04-21-2008, 10:48 PM
sahuaro sahuaro is offline
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Congratulations, LBP! You did it! I hope you are doing well.
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2001 MVA; C5-C6 disk extruded
ongoing physical therapy, exercise and massage
ESI's, oral prednisone, trigger point injections
foraminal and central stenosis C5/C6 and c6/C7
2007 EMG/nerve conduction shows pattern of chronic radiculopathy
January, 2008: Prestige ST Artificial Disk Replacement, C5/6
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  #19  
Old 04-22-2008, 12:55 AM
LBP LBP is offline
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Thanks sahuaro. I am doing fine. It is such a painful recovery. more than I expected even after reading all the posts here. I am supposed to be mobile but something I did today way overdid it....took about 8 hrs to get back into the lower level of pain on percocet. I am absolutely dreading the plane ride home next week. I cant imagine how difficult it will be and how long it will take for the nerves to calm down once I am able to lay down in my own bed.

Well it has been a very long and very frustrating road to get this surgery. To others still fighting, keep looking for ways to get what you need. Don't give up. Look for new alternatives whether it's applying to a different insurance plan at your current job, changing jobs to get different insurance, research what plans are avail to individuals in your state and paying premiums out of pocket on an individual plan, see if you qualify for Social Security Medicare Disability and if so what plans are offered in your area etc. Do what you have to, to get to where you need to be to get the right insurance, right surgery, and right surgeon! It took years to finally get my SS disability award after being denied and filing an appeal. Once I won the appeal it still seemed to take forever to get my Medicare health insurance benefits and monthly checks. It's by no means a quick or easy fix but for me I was at rock bottom with no other options and so I just had to wait it out.

For now I am focusing on my recovery and then I will have to start putting my life back together including dealing with the financial disaster I am in as well as the damage to my career I've endured because of this stupid delay in getting my health back. I'm just taking one step at a time.
__________________
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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  #20  
Old 04-22-2008, 06:59 AM
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Terry Terry is offline
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LBP:

Congratulations on a successful surgery and getting someone else to foot the bill. That is awesome. I know how it goes though with having enough money come out of your pocket you wonder who else is standing in line to take your last dollar.

Hang in there with the healing process. It is common to overdo it. I payed my dues down that road.

Please keep us informed.

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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