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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 10-23-2007, 12:10 PM
Don Don is offline
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I just got off the phone with one of our HR rep's and she told me that covered procedures are actually negotiated and decided by the employer, who purchases the coverage. She took my (supposedly anonymous) employee feedback stating that I feel ADR should be covered and is probably a better option for me than fusion from the employer's stand point by giving me a faster recovery and better long term prognosis than fusion.
. Maybe if they get a few similar suggestions, they will look into ADR and begin to cover it more. It gives me hope that I can get my employer to push the insurance company to cover ADR
Don
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Don G.

3 level DDD L5-S1 through L3-L4.
"Compressed" L5-S1 in ~1992.
Herniation at L3-L4 and L4-L5
Fusion or ADR in near future
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  #2  
Old 10-23-2007, 02:49 PM
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Don,

It sounds like you have a PPO which usually offers the least amount of benefits. I did a cost analysis of fusion versus adr and the difference was $60,000 more for the fusion. The company did not care about the price difference. I was told that all the money is pooled into a fund and if the fund runs out that year they have "back up policy" to cover the additional insurance needed. Most companies will not pay directly out of another account. It can create a "precedence" for others to request "special services"

It is a HUGE problem in the US. I think the only way this will get fixed is if everyone became insurance savy and said, enough is enough. Most people, myself included never think about my coverage until I needed it.

The insurance company is the adminstrator/paper pusher for the policy so there is no leverage with the insurance company. At the end of the day, human resource will determine if you are "eligble" for the procedure. Since most self insured companies buy the cheapest policy they can all "experimental" surgery is denied.

I am glad you voiced your concerns and hope that you have enough clout with your company that they will go out on a limb and approve your adr.
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  #3  
Old 10-23-2007, 03:19 PM
FUZZDOG FUZZDOG is offline
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hey Don..Sue....we meet again...
Don I sincerely wish you luck. My surgeon indicated that the insurance carriers are not swayed by the lower cost aspect. They are counting on "attrition" removing you from their policy coverage...or in other words that you will go away. The main reason folks "go away" is due to our disabled condition (usually)..we will not be able to continue to work. We then get fired or go out on disability leave ..if we are lucky enough to have fmla coverage our job is protected for 12 weeks. After 12 weeks we are terminated, we lose out insurance coverage unless we can afford cobra...which we can't cause we are not working. As we all know it can take 12 weeks to see a top notch specialist.
We are no longer the insurance companies problem or expense..problem solved. Stinks?
Yes! Reality? Unfortunate yes!
Cigna told my Doc that reduced pain, reduced recovery time, lower cost with ADR...and I quote
"DOES NOT MATTER"...

As far as the trials as sue mentioned most are for single level only and as my doc indicated those trial candidates are "cherry picked"...sounds like you too have alot of things going on that may make you a less than ideal trial candidate since they want no bad outcomes, ideally, so they control the factors they are able to. I guess it makes sense from the manufacturer standpoint.
Please do not think I am trying to discourage you...keep up the good fight for all that follow behind you. Like you said since you have counterparts in the UK maybe it will have some bearing on your hr policy. There is a high level corp executive in my department that was declined for cervical ADR and he meets the fda criteria exactly. He was also declined but has had contact with our HR in attempt to get them to intervene on his behalf. Should be interesting to see if the outcome is different based on his position....I am just a lowly peon.
Best of luck on the continued quest and please keep posting as many are interested in the outcome for you.
Colleen
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ACDF C5-C7 2002 with hardware
PLIF L2-S1 11/28/07
NSPINE DEVICE USED AT L2/3 ..fused with hardware to s1...
severe ddd for 10+ years tried every conservative therapy avail denied hybrid adr l2/l3 combined w fusion 3 appeals
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  #4  
Old 10-24-2007, 06:13 AM
Don Don is offline
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Thanks again Sue and Colleen,

I know, I know. I too am a lowly peon. but, I feel a challenge coming on.

Fortunately I work for a unit in which all of our management is European and very sympathetic. So, I am going to play the EU vs. US coverage card and see if they can take my side.

Fat chance I know, but I have a sick sense of humor and if this weren't about my health, I'd almost enjoy being a thorn in their cozy administrative butts.
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Don G.

3 level DDD L5-S1 through L3-L4.
"Compressed" L5-S1 in ~1992.
Herniation at L3-L4 and L4-L5
Fusion or ADR in near future
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  #5  
Old 10-24-2007, 03:12 PM
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Hey Don,

I am your biggest cheerleader Someone has to break the mold. I hope you are the one. In the meantime, keep pushing. I know what you mean about the thorn in the side, sometimes the squeaky wheel does get oiled.

My husband's boss was part of the final appeal. Two days ago he was diagnosed with a tumor in his shoulder which is laying on a vertabrae in his neck. He has no feeling in his right hand or arm. He is now a spiney? What are the odds that something you denied someone else would come back to bite you in the butt? It will be interesting to see what he has done?

Don, I wish you all the best. I am 3 weeks out from my fusion and haven't felt this good in over 10 years. My doc gives me a 10% chance of further surgery down the road. Only time will tell.
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  #6  
Old 10-26-2007, 08:50 AM
Don Don is offline
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Sue, thanks for the cheerleading! I think we are all cheerleaders for each other, even if we don't say it enough.

Good luck on your husband's treatment and on both of your recoveries. My father in law just had a tumor removed from his neck, which had been casuing numbing in his left arm for years. Unfortunately, they first did carpal tunnel surgery to no affect and then told him to wait, it was years before they discovered the tumor. By then it was major surgery and he will never get most of the strength or feeling back. So you are right, we shouldn't wait too long. But, we have the benefit of much better fusion success vs 5 or 10 years ago too. Waiting now is less an issue perhaps than a few years ago.

Take your time healing. That is what everyone says is the best course.

Don
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Don G.

3 level DDD L5-S1 through L3-L4.
"Compressed" L5-S1 in ~1992.
Herniation at L3-L4 and L4-L5
Fusion or ADR in near future
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  #7  
Old 10-26-2007, 11:00 AM
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Don,

Sorry for the confusion, it was my husband's boss who had the tumor NOT my husband. In an update, he is going to do nothing! Apparently, he is afraid of needles. In time, I am sure he will change his mind as he becames more and more numb.

Anyway, please keep in touch I look forward to a positive outcome for you.
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  #8  
Old 10-29-2007, 11:14 AM
Don Don is offline
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Sorry for the misread Sue. And glad your husband is now doing well!

I think I suffer from DBD as well as DDD!!

Don
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Don G.

3 level DDD L5-S1 through L3-L4.
"Compressed" L5-S1 in ~1992.
Herniation at L3-L4 and L4-L5
Fusion or ADR in near future
Reply With Quote
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