Judge orders ins. To pay for ADR

[Jerry5]

Commissioner’s Page

• Globalization
  FDA works to transform from a predominantly domestically-focused agency operating in a globalized economy to a modern public health regulatory agency fully prepared for a complex globalized regulatory environment.

HUH?


I thought this was the



United States


FDA?

[cruiser]

I have just sent a 40 page, professionally bound and printed brief to BCBS appealing their denial for a multilevel ADR using the M6-C device.

I hope to hear back from them soon.

http://www.spinecarealliance.org/wp-...ay-for-ADR.pdf

[bwink23]

Jerry,

I think this might be GOOD news. They may finally be realizing that our healthcare is so far behind-the-times, they are willing to be a part of a global health care standard that will bring more modern medical technology to the United States seamlessly. This is would good for all of us. They have to see how people have been taking their problems(and there MONEY) overseas due to our ancient health care system that has a huge Berlin Wall between it and the rest of the world. Hopefully the FDA is looking to knock that wall down and give people a reason to stay and put trust into our health, and give flexibility to advancing medicines. SOMETHING HAS TO GIVE SOMEDAY.

[Jerry5]

Thank you again 2Confused,

Sure enough, all that time and the VA will only consider a fusion, two weeks in a bed and 3 months with a brace.

They say it is not recommended, and are seeing more failures?

Not to say the Charite and ProDisc are NOT working, but I have talked to a few and these are tearing up their facet joints.

I had another MRI, in mid Jan, and the report from the person doing the eval of the MRI, said I had significant deterioration of the facet joints, and I have only had decompression surgery.

There are MANY people that have the M6, and are doing real well.

If anyone knows someone that has the M6, (especially in the Lumbar, in my case) and have had an MRI post op, a couple of years later, let me know if they have nn improvement in the adjoining areas, or at least not worsening.

I submitted my BC international claim this week and suspect I will get the Usual response, investigational.

Will post as I can.

[2Confused]

Hi all....
I have no real answers, but I understand there are others who have received anywhere from 60% to 100% reimbursement from Worldwide Blue...
Keep appealing!!!!

[reqmt]

If it is of any help to anyone, PubMed has dozens of studies about ADR.
There is definitely no lack of information that ADR works! If I get denied during precertification for my lumbar ADR I plan on printing out all of the studies and sending it in. ( not that I think they would take the time to read them )

I also read somewhere awhile ago that most of the time the "doctors" on the insurance review board are either not reviewing cases that are in their field of specialty, or are old school, some are even retired, and you have the right to know who is reviewing your case.

But as far as PubMed goes, I just did a search for artificial lumbar disc and tons of studies came up - most with positive results.

It just flabberghasts me that Europe has been doing ADR since the 80's and the insurance companies here have such a hard headed approach to it. It's all about how they can make the most money - gag.

[reqmt]

Originally Posted by Jerry5

Thank you again 2Confused,

Sure enough, all that time and the VA will only consider a fusion, two weeks in a bed and 3 months with a brace.

They say it is not recommended, and are seeing more failures?

Not to say the Charite and ProDisc are NOT working, but I have talked to a few and these are tearing up their facet joints.

I had another MRI, in mid Jan, and the report from the person doing the eval of the MRI, said I had significant deterioration of the facet joints, and I have only had decompression surgery.

There are MANY people that have the M6, and are doing real well.

If anyone knows someone that has the M6, (especially in the Lumbar, in my case) and have had an MRI post op, a couple of years later, let me know if they have nn improvement in the adjoining areas, or at least not worsening.

I submitted my BC international claim this week and suspect I will get the Usual response, investigational.

Will post as I can.

Jerry5,

The artificial disc is contraindicated if the facet joints have significant wear. That is why I was told, by top surgeons, my best chance would be a 1 level fusion at L5/S1, and ADR at L4/5.
However I have to switch insurance because there has been no luck with Oxford covering this procedure.

Good luck with your insurance, though!
Reqmt

[colorado babe]

Reqmt: I just had a fusion at the L5-S1 due to my bone density test a few weeks beforehand. I was so disappointed that I couldn't get the ADR but to be honest, I was kind of relieved because I didn't feel a warm fuzzy about the Pro-Disc L. It's been a week now and I feel great. I think I may have full mobility but don't want to rush things. I will have to wait until my surgeon gives me the go ahead or when I am in PT.

As far as the ADR is concerned, I also had a multi-level ADR at the C5-7 using the Mobi-C and that seems to be going great as well. All done in the USA and my insurance is covering everything but my co-pay of $11.00 per day for three days in the hospital. A friend came over yesterday and couldn't believe that I was up, dressed, cooking Tortilla soup and the house was spotless.

I believe it all has to do with the surgeon you choose. I don't see a reason to have to go all the way to Europe to get these procedures done and pay out of your pocket. If your insurance denies you then keep on fighting. It took three appeals for me before I won.

I am happy with my choice and haven't looked back. Whatever you do keep fighting. Good luck!