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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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Old 04-12-2021, 02:25 PM
l10ydchristmas l10ydchristmas is offline
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Join Date: Mar 2021
Posts: 4
Default Kaiser LP-ESP Advice

Hello All - I am new to the community and would appreciate any insight you may have on potential Kaiser Permanente insurance approval of ADR in Germany.

Based on my research, I believe the LP-ESP from Spine Innovations is the most advanced disc prothesis on the market and that Dr. Bierstedt is a great potential surgeon for implanting this device.

I would appreciate any advice regarding proper steps to build a case for insurance approval. I realize there are many obstacles but would you recommend meeting with an in-network Kaiser surgeon? Is the the ideal outcome to have them indicate surgery is required but the most advanced technology is not approved in the U.S.? Should I be seeking an explicit recommendation for implanting the LP-ESP in Germany?

Thank you again. I would appreciate any insight you have.
__________________
38 y/o male
~2003: Felt an unusual sensation when squating in the gym. Symptoms started in 2010. Have severe DDD at L5-S1.
2017: Bodysurfing collision at the beach. Neck pain at night affects sleep. Likely DDD at C5-6.
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Old 04-19-2021, 11:55 AM
Cheryl0331 Cheryl0331 is offline
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Join Date: Dec 2010
Posts: 842
Default My personal experience

Insurance usually only covers 50% out of network and will not cover the cost of a device that is not approved in the U.S. These devices are about $5000 each. So even if you get approved, you are out at least the cost of the implant, plus the 50%. Some insurance will assess a 10% penalty for not being preauthorized.
Surgical necessity is the first thing.
They may also ask for any other conservative treatments you have tried.
__________________
53 yr old female 5'7" 141 lbs. non-smoker conservative treatments failed
2007 fusion @ C4-6 peek cages, failed due to long term use of cox-2 inhibitor
2008 revised C4-6 donor bone, plate & screws
2009 fusion with Roi-C @ C3-4
2015 MRI & CT mjr ddd @ C6-7, segmental kyphosis at C7-T1, 2-level M6-C prosthesis by Dr. Clavel Barcelona Spain
2019 H.O. formed behind M6-C @ C6-7 left nerve rt & in spinal canal.
2020 Revision C6-7 to a cp-ESP prosthesis by Dr. Schmitz Dusseldorf Germany
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Old 04-26-2021, 03:59 PM
l10ydchristmas l10ydchristmas is offline
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Join Date: Mar 2021
Posts: 4
Default

Thank you Cheryl. Would you advise meeting with an in-network spine surgeon to document medical necessity and then filing a case with Kaiser for out of network approval for the surgery?

Also, if you would like to share, very interested to hear how you are feeling after having the CP - ESP implanted.
__________________
38 y/o male
~2003: Felt an unusual sensation when squating in the gym. Symptoms started in 2010. Have severe DDD at L5-S1.
2017: Bodysurfing collision at the beach. Neck pain at night affects sleep. Likely DDD at C5-6.
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