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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 06-10-2007, 08:00 AM
D. Coley D. Coley is offline
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I was approved by Blue Cross/Blue Shield March 2007 for the anterior Charite disc replacement at L5-S1 with a significant proven medical necessity. I scheduled the surgery in OKC for April 19th, 2007 with Dr Stewart Smith. I had a sinus infection therefore surgery was rescheduled for May 3, 2007. The sinus infection progressed to pneumonia therefore another re-scheduling for May 31, 2007.

I received a call from the neurosurgeons office on May 15th (2 weeks-2 days to go). They stated that there has been a "reduction in the surgeons reimbursement fee from $11,000. to $1,500.-$1,700." Of course I asked what the heck that it meant and what it had to do with me?? She stated that many of the major insurance carriers have gotten together and examined a determination of Medicare which decided that the surgeon's (one neurosurgeon and one general surgeon for the procedure) allowable fee is $1,500 to $1,700 for BOTH of their time in the OR. Insurance Cos have concluded that since Medicare decided that amount that they are only going to pay that much too. I CANT BELIEVE THIS!!!!!! My surgery has been cancelled until further notice. I immediately called Depuy/Charite Advocacy Group who knew me well as they had been ready to file appeal and fight if BC/BS did not approve me right from the start for the disc, they did not have any idea what I was talking about on the reduction of fees and immediately got in touch with the neurosurgeon's office to get the documentation from them. I called BC/BS in New York and they did not know of any problem with the reimbursement and said that it must be at the local level in Oklahoma (in-network ppo issue where all the bills for the surgery is submitted).

I went in for a follow up with Dr. Smith on May 22, 2007 and we talked about this situation, he is horrified at this development with the insurance companies!!! He explained to me that he could not work for that kind of pay which is alloted as $1500 to him and $200 to the general surgeon to open/close the patient. He said that NO general surgeon would work for that amount either. I completely understand!! This has been a long journey and I am SO mad at the insurance company that I pay $600. a month premium (by the way is on COBRA coverage and will expire at the end of this year).

I told Dr. Smith that I would wait a few weeks to give time for this nightmare to be worked out and hopefully get resolved but what are some other surgery options available EXCEPT regular anterior fusion???

Dr. Smith told me about a NEW alternative minimal invasive fusion procedure called the AxiaLIF which web site is Trans1.com. He said he had done six since the first of the year with GOOD results and said it was definately a "viable alternative to disc replacement". Has anyone had this done or know anything about it??? Please respond because I am climbing out of my skin with increasing pain and intend to call Dr Smith toward the end of this week and say "Set AxiaLIF Up for the end of the month, I can't wait anymore!!" Please help if you can.

36 year old female
5' 6" - very small framed
100# to 110# max

<LI>1990-Natural Child Birth (7# 6oz)
<LI>1994-Natural Child Birth (6# 13oz)
<LI>1989-2006 heavy lifting in career
<LI>2003-3/2006 constant Chiropractor Visits
<LI>7/2006 MRI of lumbar
<LI>8/2006- Physical therapy, cortizone injections, lots of pain
<LI>12/15/2006 Discogram of lumbar..ouch!
<LI>4/19/2007 Scheduled for Charite disc @ L5-S1
<LI>5/15/2007 Surgery cancelled for reduction of fee reimbursement
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Old 06-10-2007, 08:16 AM
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Harrison Harrison is offline
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D.,

I am afraid that everything you stated was true – the insurance companies did get together a while ago and “colluded” to reduce the reimbursement fees for disc replacement. This is tantamount to eliminating the option for both doctors and patients!

More on this in the Oprah post in the Big Bucket...
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Fell on my ***winter 2003, Canceled fusion April 6 2004
Reborn June 25th, 2004, L5-S1 ADR Charite in Boston
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  #3  
Old 06-10-2007, 08:41 AM
LBP LBP is offline
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Wow this is getting out of control....a story for Oprah?

I beginning to wonder if there's some kind of RICO law suit brewing. Relating to organized insurance fraud and embezzling our insurance premiums, mail fraud????

Maybe you should make a call to the district attorney's office? It just doesn't seem legal that insurance companies could get together and force policy this way. Private insurers are for profit...Medicare is a federal progam for elderly and disabled persons...the same standards should not apply. this just smacks of fraud and interferrence with free competition/commererce???? I don't know alot about this but if you got these kinds of facts, it's worth a phone call!
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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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Old 06-10-2007, 09:16 AM
ZorroSF ZorroSF is offline
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We don't know your condition precisely, so we couldn't recommend fusion over a motion control device like ADR. If your facet joints are bad, then receiving ADR will make them much worse as I have found out personally. However, if your spine is healthy and there are no other degenerating levels and you don't suffer from scoliosis or any other imbalance then ADR is for you.

It's almost better to just go through with the operation and get a laywer to file a greviance later. If you have a medical necessity and you don't receive treatment ASAP then you're degeneration will start moving up level by level.

I waited too long and now after the op it's moving up a level. Right now I am stuck with the $10,000 doctor bill, but the insurance did pay for most of the hospital bill.

Just an FYI, my doctor's office told me the op was covered and now insurance is telling me it's not. since my doctor's office has been negligent from the start, I'm going to have to believe my insurance company on this one.

I'm in for one hell of a greviance fight, just like everyone else here that can't afford this medical care. BTW I have blue shield of california and I pay $400/month plus deductables and co-pays. Probaably about $1000+/month and I get nothing out of it, but shrugged shoulders from doctors.
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***********************
1/2006 DDD L5/S1

Prodisc St. Mary's 12/2006 not diagnosed properly pre-op and now have DDD L4/L5, facet calcification L5-S1/L4-L5, mild scoliosis and left knee pain. DDD: C3 through C6
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Old 06-10-2007, 10:29 AM
ZorroSF ZorroSF is offline
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I just checked out that site on AxiaLIF. That looks like an interesting surgery. What is the material they use to replace the diseased disc with?
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***********************
1/2006 DDD L5/S1

Prodisc St. Mary's 12/2006 not diagnosed properly pre-op and now have DDD L4/L5, facet calcification L5-S1/L4-L5, mild scoliosis and left knee pain. DDD: C3 through C6
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Old 06-10-2007, 10:59 AM
D. Coley D. Coley is offline
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It just indicates that it is a bone growth material is inserted in place of the nucleus?? I requested the free information and received it last week. WOW. Looks like an option.

My problem summarized on the MRI as:
L4-5 central canal stenosis and bilateral neural foraminal stenosis secondary to bilateral facet hypertrophy and broad based annular disc bulge
AND
L5-S1 disc desiccation, left neural foraminal stenosis secondary to bilateral facet hypertrophy, left greater than right.

I wonder if the report has the two descriptions reversed because they are worried about L5-S1 and discogram confirmed L5-S1 wouldn't hold any fluid. I know that I'm at the end of the road in tolerating the pain.
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Old 06-10-2007, 11:09 AM
D. Coley D. Coley is offline
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LBP,
The surgeon is SO pissed. He was livid when I went in to see him and was dictating letters every direction. He copied all my documents and contact information for people I had talked to at Charite and at BC/BS. There were TWO people in his office working non-stop on this issue. I told them that I would give them a few weeks to try to get something done and/or for me to check on the AxiaLIF procedure. That has been since May 22, 2007 so I'm calling at the end on this week to schedule the other surgery. I can't wait anymore, I'm suffering too bad!!!
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  #8  
Old 06-10-2007, 11:46 AM
ZorroSF ZorroSF is offline
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since you have stenosis, I'd get two or three opinions before you have surgery. I am no doctor, so don't believe anyone here over the advice of one. However, if you have a narrowing of the spinal canal, I am not so sure ADR would be able to fix that entirely. In fact I am not so sure fusion would fix that. it almost sounds like you need ADR and X-Stop. It really depends on how bad the stenosis it.

I know there are others here that have undergone that type of pain. I hope they see this thread and add some feedback.
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***********************
1/2006 DDD L5/S1

Prodisc St. Mary's 12/2006 not diagnosed properly pre-op and now have DDD L4/L5, facet calcification L5-S1/L4-L5, mild scoliosis and left knee pain. DDD: C3 through C6
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  #9  
Old 06-10-2007, 12:02 PM
LBP LBP is offline
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Coley,

with the news about the ins companies getting together and almost seeming to collude on how to create a new policy...I am wondering if there is anything rising to the level of criminal activity for a district attorney to investigate...not just an invidual civil lawsuit. Your facts are very unique. Do you have anything in writing about the reasononing? Like there was a meeting with out ins co to pay only what medicare is paying?

Re your pain and surgery. I am sorry for your pain and I don't know anything about the other procedure you mentioned. best of luck. I just find what happened to you so alarming for the future of ADR.
__________________
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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  #10  
Old 06-10-2007, 11:13 PM
D. Coley D. Coley is offline
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LBP,
The surgeons office has the notification letter about the fee reduction so I believe it is in writing including the reasoning. I too am VERY appalled at the chain of events and like I said... I only have COBRA coverage until the end of the year and if I don't do something then I will fall under "pre-existing condition" if I try to get future coverage. I just can't believe this is happening!!!!! Last month I was thinking Option A is disc replacement and Option B is fusion if there were any problems. NOW the ins co has decided that I have to do Option B-Fusion and if there are problems then I'm SCREWED. I am SO VERY ANGRY that I pay them $600. a month to take away my choices and compare me to welfare and elderly coverage persons!!! I have nothing against those people but I am not getting anything for free
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