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  #11  
Old 08-27-2014, 10:48 AM
Optimistic Optimistic is offline
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Quote:
Originally Posted by colorado babe View Post
I just posted a long response and when I hit send it said I was not logged in when I was. I have Tricare Prime and all my problems with my back are service related and I am rated 80 percent disabled with the VA. I will try and respond later when I have time. I am currently in nj visiting family. It might not be until Tuesday but I would be happy to share all my info with everyone. #1 key, get your congressman involved and your surgeon in the appeal process. Also evidence-based practices and studies showing that ADR is better, cheaper, faster recovery rate and hospital stay than Fusion. let them know that you have exhausted every option with eastern and western medicine and that you refuse to get a fusion. I also told the third party that It was my body and I should have a say on what is best for me and my body. Will post later when I have more time.
Colorado Babe - you refer to evidence-based practices & studies showing ADR is better and cheaper than fusion. Can you share this information? As many people are going through insurance like you are, either pre-surgery or post-surgery, this documentation is very relevant. While we all have different insurance carriers and different individual circumstances, the same evidence can readily be used.

If you prefer to pm me, I am available.
__________________
1989 – herniated disc at L5-S1
1992 – L5-S1 broad bulging; right L5 nerve root compression; impingement on S1 root within spinal canal;
2006 – DDD L3-S1; disk bulge at L3-L4 and mild facet/ligmentous hypertrophy; L4-L5 large herniated disc; facet/ligmentous hypertrophy with stenosis; disc herniation & dessication at L5-S1;
2013/2014 – Dessication and significant disc height loss at L4-L5 & L5-S1; L3-L4 disc bulge with hypertrophy; mild spinal stenosis; Grade 1 anterolisthesis (3mm); L4-L5 - marginal spurring and moderate hypertrophy causing neuroforaminal narrowing; L5-S1 - moderate-severe neuroforaminal narrowing; lumbar lordosis is straightening.

New pains & functional limitations in late 2013 led to exploring ADR procedures. Consulted with 8 surgeons domestically and 9 in Europe.
May 2014 – Anterior and posterior incisions in a 5-hour surgery resulted in 2 M-6s and one facet joint prosthesis (dynamic stabilization system). On the road to full recovery.
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  #12  
Old 09-01-2014, 11:17 AM
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colorado babe colorado babe is offline
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Here are some of the articles that I used in my third appeal from Tricare to an outside agency Kepro that overturned Tricare:

1. Comparison of artificial total disc replacement versus fusion for lumbar degenerative disc disease: a meta-analysis of randomized controlled trials
2. Disc replacement may offer advantages in cost and outcomes over spinal fusion | Orthopedics
3. Cervical artificial disc replacement versus fusion in the cervical spine: a systematic review comparing multilevel versus single-level surgery
4. http://www.adrsupport.org/forums/f43...pay-adr-12341/
Most importantly, please include a letter from your congressman asking to reconsider the findings for the patient and also an office note from your surgeon noting your symptoms when they started and their conclusion/diagnosis, etc. Include a letter that you have written (See below)


KePro
Attn: Reconsideration & Appeals
777 East Park Drive
Harrisburg, PA 17111

August 7, 2014

To Whom It May Concern:

This letter is written to request for a second level reconsideration to the TQMC for a two level cervical and lumbar total disc replacement. For the past 16 years I have been suffering from Degenerative Disc Disease, severe headaches, pain in my neck, shoulders, upper and lower back, numbness in my arms, legs, spasms in my legs, feet and hands and severe sciatica. The degenerative disc disease goes back to 1998 when I was serving in the USAF at Peterson Air Force Base. My symptoms have progressed through the years to the point that I can no longer endure the pain anymore and am suffering from severe depression due to the chronic pain

I have tried to avoid surgery by utilizing traditional western and eastern medical means. Nothing has brought me relief. I was given an upper lumbar steroid injection that caused a severe allergic reaction that put me on FMLA and Short Term Disability on March 5, 2014.

There has been no improvement in my cervical and lumbar spine even though I regularly follow-up with my Primary Care doctors at the VA and through Tricare Providers. Through the years, I have received care with pain management doctors, a Rheumatologist, Physical Therapists and within the past 5 months I have been seen by a Psychologist for severe depression, and two surgeons for consultations. One surgeon that I consulted with (Dr. Chad Prusmack) in May, suggested another upper lumbar injection or a discectomy or fusion. Since I already received an injection on January 31, 2014 that caused havoc in my body I did not consent to this. Dr. Prusmack also discussed fusion, discectomy and a couple other procedures be he couldn’t guarantee that the symptoms I am experiencing would dissipate.

On June 19, 2014 I went to see an Orthopedic Surgeon (Dr. Kenneth Pettine) who came highly recommended and he was on the Tricare Provider list. When I went to my appointment I was immediately impressed with Dr. Pettine’s thoroughness and professionalism. At the appointment he and his staff informed me that I was not a candidate for stem cell procedure for the Degenerative Disc Disease after reviewing my past MRI’s and the x-rays. However, he did inform me that he could perform a two-level cervical and lumbar total disc replacement by using the ProDisc-L which was determined on August 14, 2006 to be safe and effective and approved for use in the United States, under the Federal Food, Drug and Cosmetic Act.. He informed me that trials conducted over the last five years have shown significant advantages of an artificial disc over a fusion (see letter from Dr. Pettine attached). I knew immediately after my three hour appointment with him and his staff that this was the procedure that I felt was best for me and for my body and I wanted him to perform this surgery after spending hours on the internet researching Artificial Disc Replacement vs Fusions.

On July 2, 2014 Dr. Pettine’s office sent the order to United Health Care which is the contractor for Tricare (my insurance provider) for approval to perform the surgery. Tricare denied the procedure and stated it was experimental. I submitted an appeal and was notified by Tricare on July 29th via phone call and letter on August 4 that they had denied the request again because they can only approve one level and not multiple levels on the cervical and that the lumbar code was on the government no pay list.

During the last few days, I have done further research on the internet that indicates that disc replacement may offer advantages in cost and outcomes over a spinal fusion (See Attachment 1) and that total disc replacement has been proved to show significant safety and efficiency comparable to lumbar fusion (See Attachment 2) and also (See Attachment 3) the literature suggests that outcomes are at least similar for multi-level cervical artificial disc Replacement (CADR) and Artificial Cervical Discectomy and Fusion.

Therefore, I am requesting that KePro to please consider and approve Dr. Pettine’s request to perform a multi-level Artificial Disc Replacement on my cervical spine and a single level on the Lumbar Spine.

I am attaching copies of extracts that I pulled from the internet as well as a letter of recommendation from Dr. Pettine. If you should have any questions or concerns, please feel free to contact me at xxx-xxx-xxx. Thank you for your time and consideration. I look forward to hearing back from you.

Sincerely,

XXXXXXX
__________________
1998- Injured neck and back in USAF
2011 - Started experiencing Severe Symptoms, Migranes, numbness, spasms in legs and feet and sciatica.
Feb 2014 - Received upper Lumbar Injection - Severe Allergy to injection
Mar 2014 - MRI of Cervical and Lumbar, protruding disc in C3-7, Herniated Disc in L5/S1, placed on STD and FMLA )
July 2014 - Stem Cell Procedure performed
Oct 20, 2014 - ADR (MOBI-C) at C5-7 and Anterior Fusion at L5/S1 by Dr. Pettine and Dr. Techy

Last edited by colorado babe; 09-02-2014 at 09:54 AM.
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  #13  
Old 09-10-2014, 12:20 PM
Optimistic Optimistic is offline
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Colorado Babe,
Thank you for taking the time & effort to list the articles and share your letter. I was denied pre-approval (from Cigna, not Tricare) for a 3-level hybrid lumbar procedure (2-level ADR & 1-level fusion) & ended up going to Europe for a 3-level motion preservation procedure. Instead of filing an appeal, I decided (with the input of my surgeon's office) to file a new claim based on what was actually done.

Rather than filing all of the reasons why they should approve, I will keep all this data in my back pocket in the event they deny the claim. At that time, I can focus on the reasons for the denial and prepare a comprehensive appeal.

Thanks again for your support. Good luck on your procedure next month, October 20th if I recall.
__________________
1989 – herniated disc at L5-S1
1992 – L5-S1 broad bulging; right L5 nerve root compression; impingement on S1 root within spinal canal;
2006 – DDD L3-S1; disk bulge at L3-L4 and mild facet/ligmentous hypertrophy; L4-L5 large herniated disc; facet/ligmentous hypertrophy with stenosis; disc herniation & dessication at L5-S1;
2013/2014 – Dessication and significant disc height loss at L4-L5 & L5-S1; L3-L4 disc bulge with hypertrophy; mild spinal stenosis; Grade 1 anterolisthesis (3mm); L4-L5 - marginal spurring and moderate hypertrophy causing neuroforaminal narrowing; L5-S1 - moderate-severe neuroforaminal narrowing; lumbar lordosis is straightening.

New pains & functional limitations in late 2013 led to exploring ADR procedures. Consulted with 8 surgeons domestically and 9 in Europe.
May 2014 – Anterior and posterior incisions in a 5-hour surgery resulted in 2 M-6s and one facet joint prosthesis (dynamic stabilization system). On the road to full recovery.
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  #14  
Old 09-10-2014, 12:25 PM
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colorado babe colorado babe is offline
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Join Date: Aug 2014
Posts: 345
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You're welcome and thanks you are correct. Surgery is scheduled for October 20th.
__________________
1998- Injured neck and back in USAF
2011 - Started experiencing Severe Symptoms, Migranes, numbness, spasms in legs and feet and sciatica.
Feb 2014 - Received upper Lumbar Injection - Severe Allergy to injection
Mar 2014 - MRI of Cervical and Lumbar, protruding disc in C3-7, Herniated Disc in L5/S1, placed on STD and FMLA )
July 2014 - Stem Cell Procedure performed
Oct 20, 2014 - ADR (MOBI-C) at C5-7 and Anterior Fusion at L5/S1 by Dr. Pettine and Dr. Techy
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