Did your insurance pay? Let's help one another - Page 5

bmills · #41 04-14-2005, 11:04 PM

Yes there are ADR providers in my group and state.

I'm waiting for the answer from the second level appeal. I think my attorney's point should have been clear to the appeals committee. My policy really requires it to be covered due to adequate peer review data on the subject.

Brady

biffnoble · #42 04-15-2005, 12:07 AM

One wonders, for those of us that won't have FDA clearance for some years to come, how far the above arguments would go to support getting ADR overseas.

My sense is not very far with an HMO.

Juli · #43 04-15-2005, 01:13 PM

Biff, is that because you are a cervie? What is it that the FDA hasn't approved yet for you?

biffnoble · #44 04-15-2005, 01:58 PM

Hi Juli:

In the USA FDA approval (+ off label use) allows multi-level lumbar ADR implantation.

Cervical ADR lags behind (many metrics) lumbar ADR. The only FDA approved use is single level with no adjacent disease. Anyone that dosn't meet this criteria is SOL. I'm SOL. The only way that multi-level cervical ADR can be procured is overseas primarily, in Germany. See for example the story of Christy B..

Overseas cervical ADR may or may not be ins. covered, ditto post-op and long term care.

So although the world of the lumbie seeking ADR in the USA isn't peaches and cream it's way ahead of the cervie world. Hope this answers your question.

Good luck.

Juli · #45 04-15-2005, 02:05 PM

Wow, I didn't know they had distinguished between the two. Sorry to hear that as I know how difficult it is already. Thanks for the answer though, very informative as always.

walker · #46 04-16-2005, 05:52 PM

Wow, you guys. There is SO much information being shared here. I am especially happy to learn about the "ammo" you guys (bmills) are using in your fight for what's right! I have compiled an amazing about of info from this site and from the discussion boards for my fight. Keep it up---PLEASE!!!

biffnoble · #47 04-16-2005, 09:40 PM

Hi All:

Re: Multi-level Cervical ADR.

New info (for me): Multi-level Cervical ADR is possible in cases where the surgeon has determined the need for "compassionate care exemption". My understanding is that a 3-level Cervical ADR has been performed in the US based on a "compassionate care exemption". Mark of course would be the final authority on this. Maybe we could get a multi-level US ADR Cervie to post here.

mmglobal · #48 04-16-2005, 09:53 PM

I'm not a final authority on anything... but I do know of a 3-level ProDisc-C done in the US.

Mark

biffnoble · #49 04-16-2005, 10:22 PM

A quote (not from Biffnoble):

"Actually, the surgeons can use the discs as they see fit, it's mostly basically for insurance purposes that the FDA approval comes into play. It's not that the surgery can't be done, it's a matter of who is willing to pay for it. I am having to go before the worker's comp board to convince them that a 2 level surgery is necessary for me, so they will pay for it."

If true this statement has a lot of interesting ramifications.

cavalib · #50 04-18-2005, 10:51 AM

For those of you who I have talked to, I just wanted to let you know my insurance denied my claim for the ADR surgery. I just foind out on Friday and was a little upset but at the same time I was expecting it. I was asked if I wanted to appeal, but I decided I didn't want to. After reading all the stories and what people have gone through with the appeals, I figured it wasn't worth the headache. I guess my only option now is a fusion. Do they do fusions where they don't have to take bone from the hip?