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  #1  
Old 10-18-2010, 03:03 PM
Robinson14 Robinson14 is offline
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Hello everyone, my name is Richard and I have a large L5-S1 disc herniation with s1 nerve compression and nerve damage. I was referred to this website by my surgeon to get advice. He wanted to do an ADR Prodisc, however my insurance(Highmark BCBS) denied my claim. Ive tried contacting them to appeal it but they say they just wont cover it. He says he can do a fusion, but there would be major obstacles after. Thus far my way of life is diminishing. Can anyone help me out? I would greatly appreciate any advice. Thanks.
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  #2  
Old 10-18-2010, 05:11 PM
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jss jss is offline
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Robinson,

Condolences on the condition and on the added and completely unnecessary insurance hassle. Unlike you I am (was) a cervical sufferer, but I locked in an eleven month challenge with my insurance company for reimbursement of a double ADR surgery.

If you are not in so much agony that you can put your surgery off for a couple of months, I do believe that you have a couple of options in getting your insurance company to pay.

Option 1

In 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 think that I'll be sending that appeal in this week. The book is short, 180 pages, and easy to read. But the ensuing research on your part will take multiple weeks.

Option 2

If you are willing to travel out of country for surgery (doing so is replete with unique risks), it may not be impossible to convince your carrier 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 lumbar ADR for less than it will cost for ALIF here in the US. You will need to:
  1. Determine the cost of an ALIF at your local hospital (your case manager with your insurance carrier should be willing to provide this information)
  2. Locate foreign doctors that perform ADR for less than the price your carrier will pay for a local ALIF. 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 your carrier. 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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  #3  
Old 10-18-2010, 05:29 PM
Robinson14 Robinson14 is offline
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Jeff,

I really appreciate your advice on this matter. I would really like to have the adr surgery opposed to the fusion, but after fighting with the insurance company for months now I feel its time to have something done. I have disabling pain in my right leg and back, along with extreme numbness. I drag my right leg and feel like im not going to be able to walk at times. I had a work related injury and am 22 years old. I have a 14 month old daughter and not being able to do things with her is taking a major tole on my mind. The things I used to take for granted are extremely difficult(walking, sitting, standing). What are the outcomes after the adr surgery? What kind of restrictions are you faced with? I worked a very hard manual labor job and am scared im not going to be able to return to it.
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Old 10-18-2010, 08:27 PM
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Harrison Harrison is offline
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Robinson,

Please see the Surgical Outcome forum, sift & read through the outcomes carefully. Also, consider the DVD which was created for people like you, here's the trailer.

Thanks Jeff, for your helpful post!
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"Harrison" - info (at) adrsupport.org
Fell on my ***winter 2003, Canceled fusion April 6 2004
Reborn June 25th, 2004, L5-S1 ADR Charite in Boston
Founder & moderator of ADRSupport - 2004
Founder Arthroplasty Patient Foundation a 501(c)(3) - 2006
Creator & producer, Why Am I Still Sick? - 2012
Donate www.arthropatient.org/about/donate
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  #5  
Old 10-20-2010, 11:10 AM
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jss jss is offline
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Quote:
Originally Posted by Robinson14 View Post
... What are the outcomes after the adr surgery? What kind of restrictions are you faced with? I worked a very hard manual labor job and am scared im not going to be able to return to it.
Robinson, I have neckties that are older than you, and I sure hate that you're having this at only 22.

I have no physical limitations due to my double ADR. Since that surgery I have run marathons and lifted and carried objects whose weight approached 200lbs. However, all of my surgeries were cervical, which from what I've read is a tip toe through the tulips compared with lumbar. I don't know what limitations you'll have. Once you have surgery PLEASE consult your doctor before returning to your physically demanding job.

You may have one other option for getting ADR that I didn't consider previously.

This study is for a new lumbar investigational ADR device, and they are currently recruiting participants. It is for the TRIUMPH® Artificial Disc. I know NOTHING about that device and so can't speak for/against it. The study is non-randomized and there is no control arm; which means that you don't stand a chance of waking up from surgery with fusion.

If you are willing to receive an ADR as part of an investigational study, point your browser at clinicaltrials.gov and search for "artificial disc". There will be a lot of data to weed through, but it's a place to start.

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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  #6  
Old 10-20-2010, 12:59 PM
annapurna annapurna is offline
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One other option you might be able to push for if your company self-funds its insurance: the recovery from ADR surgery is comparatively faster than fusion and may be able to be shown to be more likely to get you back to work faster and more completely. If your company is willing to work the appeal with you, they might be able to argue to get you ADR to get you back to work faster. Practically, fusion is going to have you on limited duty work for quite a while. Hopefully, it will work well and fix your pain but the fusion itself will have you on restricted lifting for months or more. You might see if your doctor could quantify that time, estimate if he/she'd do anything different if it was an ADR instead and try selling to your company.
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Laura - L5S1 Charitee
C5/6 and 6/7 Prodisc C
Facet problems L4-S1
General joint hypermobility

Jim - minor C5-6 instability and facet damage, currently using regenerative medicine to address

"There are many Annapurnas in the lives of men" Maurice Herzog
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  #7  
Old 10-21-2010, 11:06 PM
Hooch Hooch is offline
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Gday,

Having a fusion is never a simple thing, but if you had to choose a lumbar level it would be l5-s1. Very little movement there and the mechanics of your back wont change nearly as much as compared with a two level lumbar fusion.

Get a few opinions before you do anything.

Good luck.
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  #8  
Old 10-22-2010, 02:52 AM
Robinson14 Robinson14 is offline
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I really appreciate everyones sincerity in this matter. In the recent months I've had an extremely hard time with the insurance company and my employer. Both my doctor and I have tried to convince them that if I had the adr I would be able to return to work much quicker, but they just dont seem to wanna pay for it. My work doesn't have a light duty program, so I don't know what the consequences of that will be. My doctor tells me that if I have fusion at this age that there is a good possiblity of future surgery down the road. I have been in disabling pain for months, have tried every conservative treatment there is and still can't get any release, so I guess I am going to go with the fusion.
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  #9  
Old 10-22-2010, 10:16 AM
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jss jss is offline
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Robinson, I hate that this decision had to be made based on the actions of an obstinate insurance company. Please keep us updated on when you have surgery and how you're recovering.

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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  #10  
Old 10-24-2010, 05:41 AM
Robinson14 Robinson14 is offline
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Jeff, I feel the same way. You would think they would go with the quicker recovery. I will definately keep you guys posted.
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