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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 04-25-2009, 01:54 AM
ThomasL ThomasL is offline
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Join Date: Apr 2009
Posts: 40
Exclamation HELP!!!!! which Insurance Carrier???

My company is in the process of getting bids for our 2009/2010 policy. I choose who and where we go regarding the company policy. We are based out of Washington State.

I need 2 level ADR C5/C6 C6/C7.

Where do I have the best chance of getting a surgery expenses covered?

Thx,
ThomasL
__________________
2 Level Prodisc-C on 8/13 by Dr Delamarter at Cedar Sinai
  • C5-C6 60%+ compression of cord and severe foraminal stenosis.
  • C6-7 central stenosis with mild, subtile ventral spinal cord flattening. Severe Bilateral neuroforaminal stenosis secondary to foraminal disc bulging and endplate osseous spurs. Bilateral radiculopathy.
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  #2  
Old 04-25-2009, 08:47 AM
Deborah Deborah is offline
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That's kind of a loaded question, since it's not FDA approved for 2 level yet, to my knowledge. It's unlikely in a normal situation that any insurance would approve. FDA should have a reply out soon (in this year) but you never know. If you have a doctor already, his office may know who they think is likely or if there is a clinical trial available for you and who would cover that.

I believe Aetna was the first to fairly consistently cover Prodisc, one level (after it was FDA approved).
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Deborah

C3-5 fused 2001
Hub: C3/4 fused 2001
Hub: TDR Prodisc L4/5, Fusion L5/S1 on 3/3/2009
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  #3  
Old 07-07-2009, 11:47 AM
reddirt reddirt is offline
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A friend of mine in the US flew to France w/ $15K in hand & had a 2 level lumbar disc replacement surgery several years ago. Overseas out of pocket is 1 option.

I recently looked at *individual* policies & ruled out United b/c of their "$2000 maximum benefit outpatient spine and back per year"
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  #4  
Old 07-11-2009, 12:19 AM
LBP LBP is offline
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Aetna is your best US chance for ADR coverage...but make sure you're not in an HMO and you may not want the cheapest option of Aetna plans. Different plans within companies can make huge differences in what is covered.

for European surgery costs...you have to factor in the current exchange rate.
__________________
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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  #5  
Old 07-25-2009, 12:02 PM
ThomasL ThomasL is offline
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Quote:
Originally Posted by LBP View Post
Aetna is your best US chance for ADR coverage...but make sure you're not in an HMO and you may not want the cheapest option of Aetna plans. Different plans within companies can make huge differences in what is covered.

for European surgery costs...you have to factor in the current exchange rate.
I switched to Aetna for this reason - I need a 2 level cervical. The 1st submission was rejected due to being "experimental". Dr. Delamarter is in the process of fighting this one for me. If the 2nd submission fails, he is pushing for a peer to peer review of my case. Surgery is 8/13.

IF Aetna still rejects, the difference in cost between a 2 level and a 3 level is small - about $2000 of extra surgery time at the hospital and a bit more to the docs.

thx!
Thomas
__________________
2 Level Prodisc-C on 8/13 by Dr Delamarter at Cedar Sinai
  • C5-C6 60%+ compression of cord and severe foraminal stenosis.
  • C6-7 central stenosis with mild, subtile ventral spinal cord flattening. Severe Bilateral neuroforaminal stenosis secondary to foraminal disc bulging and endplate osseous spurs. Bilateral radiculopathy.
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  #6  
Old 07-30-2009, 05:47 PM
terigrx terigrx is offline
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Default Cervical in France

Who performed the surgery in France and how to reach them? We are financially not able to go to Germany as this for a single level cervical ADR is $30,000 US. France seems much more reasonable? Any insight anyone?
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  #7  
Old 08-11-2009, 11:06 PM
ThomasL ThomasL is offline
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Join Date: Apr 2009
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To be clear. Aetna sucks.... They have refused 3x to get a 2 level ADR done. I can't wait. I'm paying out of pocket and will go after them with lawyers.

Surgery is the 13th of August.

thx!
Thomas
__________________
2 Level Prodisc-C on 8/13 by Dr Delamarter at Cedar Sinai
  • C5-C6 60%+ compression of cord and severe foraminal stenosis.
  • C6-7 central stenosis with mild, subtile ventral spinal cord flattening. Severe Bilateral neuroforaminal stenosis secondary to foraminal disc bulging and endplate osseous spurs. Bilateral radiculopathy.
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  #8  
Old 08-12-2009, 07:20 PM
LBP LBP is offline
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Join Date: Aug 2005
Posts: 446
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You are the first person I've ever heard of that has been denied ADR surgery with Aetna. I had a 2 level lumbar and there was no fight, no appeal, just approved immediately once I finally got them as my insurer. As my profile states, I had no luck with my appeals through Pacificare and UHC AND IT all changed with Aetna, and I picked Aetna based on comments from people on this forum who had Aetna.

What specific Aetna plan are you on? That may have something to do with it. Do you have a PPO, an HMO, and did you select the least or most expensive option, is it through your employer? are you limited to one plan with Aetna?

I dont know much about the differences of ADR for cervical vs lumbar, but at the time I was approved, Prodisc lumbar was still only FDA approved for 1 level, I don't think the FDA has yet approved the 2 level arm of the Prodisc clinical trial.

the only other thing I can think of is your surgeon. Maybe that weighs into the equation??? I picked a surgeon who participated in the 2 level lumbar Prodics clinical trial so he was very experienced in the procedure. I have no idea if that matters. I had the same surgeon when I tried to have a 2 level Charite (before prodisc was approved) but UHC denied it.

Which disc are you trying to get and what is the FDA status on that disc or other disc implants. I honestly don't know why you are hitting a wall. I am surprised that no one else has posted with a similar aetna story. Have you done a search with Aetna? I haven't monitored this forum as much since I had my surgery but before my surgery, Aetna was the only company consistently giving a green light.
__________________
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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  #9  
Old 08-14-2009, 09:24 PM
Jack Jack is offline
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Join Date: Jul 2009
Posts: 120
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Different states have different insurance, even within the same company. It really pays to read your policy. I've been through this type of thing with insurance companies. The time to get tough is before getting a procedure or test done. Workers Comp is a totally different animal. Lawyers seem to have better luck with WC. The plain old garden variety insurance company is pretty explicit from a legal perspective what they will and will not cover.
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