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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
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Hi everyone,
I was wondering if anyone had any help, guidance, or approvals for ADR from Tricare? I received my denial letter on Friday and sent in the below letter for reconsideration ![]() 26 July 2010 TriWest Health Care Alliance Reconsideration Department PO BOX 86508 Phoenix, AZ 85080 To Whom it May Concern: I am writing to request a formal appeal of the rejected proposed treatment, cervical disc arthroplasty, for the following diagnosis: * Cervical Disc Degeneration * Chronic pain to neck and to right scapular region * Chronic Muscle spasms to neck and to right scapular region * Nerve Palsy to right upper shoulder and arm * Cervical Radiculopathy * Spondyloarthropaty of cervical spine * Loss of normal lordotic curvatrure of the cervical spine * Mild disc desiccation * Headaches All of my above listed medical diagnosis are documented with associated numerous tests that I have been put through since approximately 2007. Sadly, I have attempted and failed numerous rounds of conservative treatment only to live in constant pain and always scared and guarded to not have an acute spasm which feels like I have been struck by lightning in the back of my neck. This is also affecting my career because of the numerous medications and vigorous expectations that are demanded by my profession. I can no longer work as an emergency-trauma Registered Nurse Specialist. I am currently in graduate school for Acute Care Nurse Practitioner but with my chronic neck problems this could shatter my dream, as well. At my age a fusion would literally put me on the "bench" forever. I have three young children that I would love to conquer adventures with. With a fusion there would be serious limitations. I have tried soft c-collars, trigger point injections, Chinese acupressure, Chinese acupuncture, cupping, tens-unit, moist heat, cold therapy, cervical pillows, tempur-pedic bed, physical therapy, professional massage, chiropractic adjustments, freezing and stretching with ethyl chloride, prednisone, NSAIDS, narcotics, lyrica, neurontin, muscle relaxers, the Felix trigger point board, cervical epidural injections, facet injections and ultra sound therapy. I have literally spent thousands of dollars and have exhausted every possible remedy to relieve this horrible condition so that I can start living my life like I used to. Dr. Briggs, my neurosurgeon from the Springfield Neurological and Spine Institute, Dr. M. Akhtar Choudhary (my neurologist) and I have all agreed that the cervical disc arthroplasty is the most appropriate treatment for my condition and that I DO meet criteria for disc arthroplasty and should undergo this surgical procedure. Please find the attached documentation that may be helpful in your reconsideration of the pre-authorization claim for benefits and payments in which Tri-Care does cover for all Active Duty Soldiers, but is sadly denying their dependants of this medical necessity: * A copy of "not approved" letter * Medical Justifications for cervical disc arthroplasty * Clinical literature on disc arthroplasty * A letter from my doctor * Cost benefit analysis reports * FDA approval letter for the prestige ADR Thank you for your consideration of this much needed coverage . If there are any questions please contact me at 573-847-8246 Angela M. Barco RN, BSN I thank you in advance of guidance as to what else I can do? I am so tired of suffering.... ![]() |
#2
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There was a letter from some governmental agency to insurance companies indicating that if they were offering federal insurance, they could not second-guess the FDA by denying FDA-approved procedures, devices. etc.
I assume that would be relevant for your case. I'm sorry for being so vague but it's been a while since I was where you are (but lost my appeal to Health Net). I would guess that this letter was posted on this board 2-3 years ago. I will try to locate my copy, but you may want to do a search here. Wishing you all good luck.
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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 |
#3
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Thanks for the reply.....A good friend of mine is actually the chief of referral Management for Triwest... LOL..... The ADR procedure code is actually on their DO NOT PAY list, FDA approved or NOT...
Although I have had TriWest for over 10 years, I was given the advice that since I am a federal employee and open season is in October to just keep taking all my meds :-( and enroll in Federeal BC BS and on Jan 1st I am eligible for care and have the Neuro Surgeon send the Pre- Auth to them...... Or stay with Triwest and get a fusion because that IS a covered procedure.... So I guess I need to start reading about the different BCBS plans so in October I am ready to pick one and hope for the best.....YIKES Is your insurance company willing to pay for the fusion? ![]() |
#4
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How wonderful that you have an alternative!
I assume Health Net would have paid for fusion--which would have been 2-level and probably more expensive both for surgery and hospital stay. However, fortunately, I was able to pay out-of-pocket for ADR and I am very pleased with the outcome!
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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 |
#5
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Received my reconsideration but still denied because it is not a covered benefit...I was actually surprised but to no avail still denied, when I called they said fusion is covered....After feeling sorry for myself, I reproached the entire situation.. Military Treatment Facilities do not bill Tricare so I contacted Walter Reed Hospital and received great news, I was correct!!! I federal expressed my radiological images and medical records, they were reviewed by the neurosurgical department..Today I received a phone call that I was accepted and scheduled for a C5-C5 ADR on September 16... Now the chaos begins..flights, hotels, childcare for my kiddos , leave !!! I am so excited, relieved and now nervous!!!! So now I get to read post about after surgical procedure and what to expect woo-hoo......Angie
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#6
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That is so terrific!
But, now I'm confused: who will be paying for the surgery?
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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 |
#7
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Sorry for the delay, I received my prestige TDR C6-C7 at Walter Reed on September 16th, 2010,
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#8
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Abarco,
Really glad to hear that TRICARE finally relented and covered your cervical TDR. Had a couple quick questions I was hoping you might be able to answer (at your convenience): - What is your status relative to the military? Are you active duty, a dependent, or a retiree? The reason I ask is that I'm a veteran who recently left active duty after 13+ years, and TRICARE will no longer touch me (ie I have to deal with the VA for my service-related back issues). - Who did your procedure at WRAMC? Dr. Michael Rosner did my L5-S1 discectomy back in July 2007, and used to use the Charite for TDR. While I last met with him (this past May/June), he advised that he no longer performs TDR, as he has lost faith in the practice (believing TDR is not effective for mechanical back pain). If he is no longer doing them (as head of Neurosurgery) I'm curious who is still performing TDR there? - How did you ultimately convince TRICARE to relent and authorize the procedure? From my experience, they drag their feet at any/every opportunity, so you must have some sort of effective strategy/approach to overcome this. Hope you have a smooth recovery, and wish you the best for continued improvement! Best regards! Alan P.S. Feel free to PM me with any/all information if you prefer....
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4/07:LBP + radiculopathy=severe L5-S1 herniation , 7/07:Micro-D, 08-09:Reherniation, 09-17: periodic residual symptoms (conservative modalities to maintain "stability" = prolotherapy, ESI/nerve blocks/facet injections, chiro, massage, phys ther), 7/17 pain in neck/right shoulder radiating into hand (no trauma involved), 7-10/17 Conservative treatment to date include physical therapy/dry-needling/facet-injections (C4/5 to C6/7). Researching surgical options should progression continue. |
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