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  #1  
Old 10-09-2010, 09:51 PM
skmcpher skmcpher is offline
Junior Member
 
Join Date: Oct 2010
Posts: 4
Default Hello

I just joined this forum and I’d like to say first how nice it is to know that I’m not the only one in the world who suffers from neck pain and has had trouble with insurance.

I'm a 43 year old woman who has had some bad luck with MVA’s and that’s why I am here. My story goes like this: in May of 2001, I was an innocent front seat passenger in a car accident. I injured my neck and ended up having ACDF at C5-6 in April, 2002. After months of Physical Therapy and other treatments, I was finally pain-free in 2003. I did not know, however, that an errant screw placed during the surgery wound up in the C4-5 disc space.

My pain-free life came to a screeching halt in May, 2009, when I was once again an innocent front seat passenger in an MVA. I had neck, shoulder and back pain right away and soon began to experience numbness, tingling, weakness, and other symptoms in both arms and occasionally in my right leg and foot. Months of testing and conservative treatments did nothing for me, and I bounced from doctor to doctor until I found someone who actually seemed concerned with all the symptoms I suffered and took more action to figure out what was wrong. I underwent a discogram in January, 2010, which showed a grade 1 or 2 annular tear at C4-5 with discordant pain; and a grade 4 annular tear at C6-7 with concordant pain. My doctor suggested ADR with the Prestige disc at C6-7 but Cigna denied pre-authorization. I was suffering so much and did not want to wait to fight things out with Cigna, so I underwent ACDF at C6-7 in February, 2010. During the surgery, my doctor removed the plate and screws from the previous surgery and put in a new plate and screws at C6-7.

Unfortunately, that ACDF did not seem to help, as my pain and other symptoms continued. MRI in July was apparently negative, but another discogram later that month showed a grade 3 annular tear at C3-4 with discordant pain, a grade 4 annular tear with concordant pain at C4-5, and grade 1 anteriolysthesis at C2-3. My doctor recommended another ADR at C4-5 and suspects that removing the screw from C4-5 made that disc worse. He attempted pre-authorization for ADR with the Prestige disc again with Cigna in August; denied (“experimental”); first-level appeal just denied last week.

I am very worried that Cigna won’t approve the procedure no matter how much I appeal and even if I get an Independent Medical Review with the California Department of Insurance. I don’t have the funds to have the surgery done abroad, or even know where to start to even investigate that process. I'm suffering with every day that goes by and I really don't know how much longer I can tolerate it.

I would appreciate any advice, suggestions, or other help anyone reading this can provide. Thanks, and sorry my post was so long!
__________________
Injured in MVA, 5/2001
ACDF C5-6, 4/2002

Injured in MVA, 5/2009
C6-7 Grade 4 annular tear w/condordant pain via discography, 1/2010
ADR C6-7 requested 1/2010, Denied by insurance
ACDF C6-7, 2/2010
No pain relief.
C4-5 Grade 4 annular tear w/concordant pain via discography, 7/2010
ADR C4-5 requested 8/2010, Denied by insurance (level 2 appeal in progress)
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  #2  
Old 10-10-2010, 10:19 AM
jss's Avatar
jss jss is offline
Senior Member
 
Join Date: Nov 2009
Posts: 1,411
Default

skmcphr,

Condolences on your condition, but welcome. What a discouraging story. I have two cervical fusions and two ADRs myself and can't imagine having to have had three or four fusions. While you are unable to fund the ADR from your own pocket, I still believe that you have at least two realistic funding options.

Option 1

Before filing another appeal to Cigna, I would encourage you to read this book. The author explains how to appeal to your insurance company and win. She claims a near 100% success rate in helping others with appeals. I used her method to get my carrier to reverse its initial denial of my request for reimbursement. They've since denied on different grounds and I'm days away from sending in an appeal to that denial. The book is short, 180 pages, and easy to read. But the ensuing research on your part will take multiple weeks.

Option 2

As you are willing to travel out of country and willing to use the Prestige ADR, it may not be impossible to convince Cigna to cover an out of the country ADR. As a for profit business it should come as no surprise that they care more about profit than anything else. With some research you will be able to find ADR services in India, Thailand, Costa Rica, Mexico and other such countries in which you can receive a Prestige ADR for less than it costs for another ACDF here in the US. You will need to:
  1. Determine the cost of an ACDF at your local hospital (Cigna should be willing to provide this information)
  2. Locate foreign doctors that perform ADR for less than the price Cigna will pay for a local ACDF. I know of two web sites that you can use for this; Planet Hospital and Health Base. I used the latter and have had great success.
  3. Present the information to Cigna. If the cost difference is significant enough, you should even present your travel expenses as part of the cost. They may cover it.
If they agree to consider your offer, they will contact the provider with whom you've presented them and attempt to get an even better price.

The key for either of these options is that you have to do all of the leg work and research. If you're willing to work at it, you have a chance of getting your ADR.

Good luck!

Jeff
__________________
C4/5 - ACDF in 2000
C5/6 - ACDF in 2002
C3/4 & C6/7 - M6 ADR, Nov 2009, Barcelona
Conceded defeat to a manifestly disingenuous BCBS-TX in my quest for reimbursement, Jan 2011
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