Denied by LifeWise of Arizona

[eochs]

This is my first post on this board (which I am very happy to find)...

I live in Phoenix, AZ and am seeing Dr. Joshua Appel at The Core Institute... I wanted to see Christopher Yeung but they do not take my insurance... As it is I am extremely confident and happy with Dr. Appel...

My back pain started in January 2006 while scrubbing my bathtub... After standing up and feeling intense pain in my back I ended up getting a ride in an ambulance to the hospital a few hours later, where they shot me up with muscle relaxers and painkillers to get my L5-S1 disc to go back in place... I then started seeing doctors about my back and was diagnosed with bi-lateral pars defects at L5 and mild DDD at L5-S1... For 2 years I have done epidural injections, physical therapy, RF neuro-ablation, vicodin/ibuprofen, etc... During that time I have been told by 3 surgeons that I needed a fusion to fix my problems, but because I am only 31 they did not want me to have one...

A few months ago I had a discogram done and found out that not only do I have DDD at L5-S1, but major pain at L4-L5 as well... I just started seeing Dr. Appel about 10 days ago and he suggested a hybrid surgery with an L5-S1 fusion and L4-L5 Charite disc... After hearing this and reading about how this could save me from having fusions in the future due to degradation above the fusion I scheduled my surgery date for December 17th and was very happy...

Just heard yesterday that Lifewise of Arizona (my insurance company through work, owned by Premera)) has approved the fusion, but is calling the Charite disc "investigational"... Since it is FDA approved since 2004 I don't fully understand this, other then the obvious "they don't want to pay for an expensive operation" meaning... The doctor has spoken with the people that make the Charite disc and they are handling the appeal for me... He says they will bombard Lifewise with studies and statistics to prove that I need this surgery and that it is not investigational... I have also talked with the HR director for my company and together we spoke to our broker at Lifewise, who has promised to try to push the appeal through for me...

Since the surgery is supposed to be 3 weeks away I kind of doubt the appeal gets processed by then... My girlfriend (we live together) is a student and is off from school from next week until mid-January, so the timing would've been perfect to have her home for my recovery...

Basically, this sucks. Anyone deal with LifeWise before? Any hints/tips for me?

Eochs,

I am sorry to hear about your insurance company. I was in the same situation as you and went through all appeals (10 months) and finally had a two level fusion. My deciding factor was based on several reasons, with pain being the biggest motivator. The deal breaker for me was my diagnosis with mild facet degeneration.

I am not unhappy with my fusion and in fact, to date, have had a very good recovery. That said, I do have concerns about adjacent disc degeneration and the need for further sugery. It is my hope that insurance companies will get there act together and start supporting ADR for patients that meet the criteria but to be honest I sometimes feel as though either direction can have its own set of post surgery issues.

Best of luck with your decision and keep us posted.

[LBP]

I am sorry to hear that you too were denied ADR surgery by your private insurer.

There's lots of discussion about the "insurance warrior" as well as individual experiences.

This a something you need to make yourself as informed as possible as to making a persuasive, legal, and financial case for your surgery.
Have you read Azfamilyguy's recent posts trying to gather certain info and hints how to write an effective appeal?

When you get to the stage of your appeal when you have a right to ask for an "independent medical review) please know that in the past some of us learned that when our file was sent out for an "independent review" we were shocked to learn what kinds of doctors were reviewing our case. Don't expect them to voluntarily assign your case for reveiw by orthopaedic surgeons. You need to demand peer to peer reviews by orthopaedic surgeons. You don't want a dermatologist or PCP performing the so called "independent review."

You also want to submit proof of coverage by other insurance companies...get copies from patients to prove it. Do a cost comparison why you're a better candidate for ADR over fusion, in terms of age, health, ability to return to work faster, and the anticipation of possible future medical costs for a failed fusion or adjacent level problems for fusion vx. ADR.

Get involved so that you know you did everything you could to make your one shot at his fight a good one.

In the alternative, does your employer offer Aetna or Cigna or another insurer more ADR friendly? Can you switch or look into your own individual health insurance policy?

good luck and read stuff on the forum about aprovals and denials. I hope I'm making sense, cuz it's late at night and I am starting to feel the effects of my sleeping pills!

[AZFamilyGuy]

Sorry to hear you're going through this mess of beauracracy and profit-mongering, too.

As LBP mentioned, I've setup a thread regarding collecting info and such that should be useful to people filing appeals with their insurance companies and state agencies. As mentioned in the thread, there will be a couple changes to how we're going to do this - Harrison and I plan to have something rolled out in the very near future.

In the meantime, I've had a bit of luck PM'ing people. Read the posts on this site - there are lots of people with similar diagnoses - PM them and ask for info/help. There are some good people here trying to help each other out - you've come to the right place.

Best of luck!

[eochs]

My doctor heard back from DuPuy (Charite) today that they do not want to even try to appeal... Because of the pars defects at L5-S1 they feel I am not a good candidate for this... I really don't understand that since I thought that was the point of the hybrid surgery (fuse L5-S1 to make the pars defects stable, ADR at L4-L5)...

Waiting for the doctor himself to call me tomorrow... His nurse said he is a little apprehensive about just doing a fusion b/c of my age (31)... My thought is that after 2 years of doing conservative care doing nothing for me, that it is time to try surgery... I know that if they fuse I could/will have problems above/below in 10-15 years, but I think that by that time the ADR will be mroe common and accepted and I may be able to go that route... Not sure yet if the doctor wants to do a 1 level or 2 level fusion, will find out tomorrow...

[AZFamilyGuy]

Sorry to hear the bad news from Charite.

Yea, I've heard different opinions on back surgery being that I'm also 31 (in about a month, anyway). Some people say don't even consider it and others say that if you're that unhappy, you should do something. I'm leaning towards the second group because I want a better quality of life.

I'm hoping that I'll qualify for a hybrid or 2-level adr (and can get whichever approved by ins.), but I haven't really dug in yet with checking all the contraindications - just around the corner from getting the clear diagnosis/recommended treatment option(s) laid out for me. I have a feeling I'm going to have to manage checking the contra's myself, because I've heard horror stories on this site from people that have had doctors - even the good ones - miss one and end up having bad results because of it. It looks like your doctor is doing well with checking this stuff out so far - make sure he keeps it up and do the research yourself, too.

Good luck - let us know which way your doctor decides to go with the fusion.

[eochs]

I'm scheduled for a 2 level fusion (L5/S1 and L4/L5) on December 17th at Del Webb Hospital in Sun City West, AZ (just outside of Phoenix) with Dr. Joshua Appel... The doctor feels that if ADR is not approved (which it's not) then we should fix the pars defects and DDD at L5-S1, and DDD at L4-L5 all in one surgery...

Now I need to figure out how to get through the next 10 days without being able to take Ibuprofen!

[AZFamilyGuy]

Wow, that actually seems amazingly quick to get you in. I hope everything goes well and as someone in an almost identical situation, I will be anxious to hear about your outcome.

Best of luck and please keep us up to date on your progress!