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The Big File All issues not easily categorized in the above forums are here. Comments on general health, diet, "getting comfortable," and more are here.


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  #1  
Old 04-21-2005, 05:27 PM
sfmcfar sfmcfar is offline
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Hi all,

I saw Dr. McAfee in Towson, MD today. He's supposedly done more ADR surgeries that anyone in the country - I'm lucky that his office is only 45 minutes from my house. The good news is that he said I'm the best candidate for ADR he's ever seen. He also said that since I was in such good shape otherwise I could probably go back to my sedentary job in less than a week after surgery!

The bad news, of course, is insurance. I have MAMSI, which his surgery scheduler said has been extremely uncooperative. I'm on a MAMSI health plan for Federal Employees, and I'm hopeful that it will make a difference - I know that federal employees have additional resources for appealing insurance denial decisions, and I'm crossing my fingers that they might be more liberal with their decision making in the hopes of keeping a member of a HUGE subscriber base happy. It also seems like the few people on this board that have been approved are government employees of some sort or other, but maybe that was just my imagination.

I've started a blog at http://mynewdisk.blogspot.com as well - I'll try to keep it updated as to my status as well.

Any insurance-related suggestions are highly appreciated.

-stan
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Old 04-21-2005, 06:33 PM
Pat&Robin Pat&Robin is offline
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Hi Stan,
I don't want to be the bearer of bad news and many people here are having sucess with getting insurance to pay for their ADR, but I don't have a good story to tell. I recently posted about code problems and have been going through a nightmare the last few days here.
My husband, who needs the ADR, is a Federal Employee(post office) but has workmans' comp for his back injury right now, so maybe this is different than your case. His regular insurance is Federal BCBS which is BCBS of Illinois(which the doctors office just told me. We are seeing Dr. Geisler in Chicago, supposedly one of the more experienced surgeons in the US, involved in the trials. We saw him in October, he said Pat was a perfect candidate also, but pending some tests to see is vascular access was possible, seeing how he needs a much higher disc(L2/L3). That was done by end of November and surgery requests sent off to workers comp. We were told it would take 2-3 months. We checked weekly but would always get the run around. Then in mid-March an approval letter came in the mail. It was such a happy day.....however, short lived. Upon contacting the doctor's office, were told the wrong surgery code was approved. How could that happen, we say? Weren't the codes submitted by the doctor's office? Yes, they say, but shortly after they submitted them, the AMA assigned new codes to ADR,as a result of it becomming FDA approved. We call workers comp, they have no such code, we call blue cross, they have no such code. We were told there was no possibility of an authorization for a surgery code they don't have in their data base. After numerous phone calls the last couple of weeks, we have had many ups and downs, but we are still no further ahead. I called places like TBI and even called Dr. McAfee's office, and they told me they are billing under old codes and are under no obligation to bill the new ones until July 1, which is the story I get from the AMA website and also a personal email from the AMA. See, our doctor's office claims that the hospital will no longer schedule a surgery unless they have authorizaiotn with the new codes, as they've been stiffed before. How did we get so lucky to get, apparently, the only hospital/doctor in the US that won't bill the old codes. I pointed out what the AMA says and they claim that they talked to someone higher up and the story is that it's fraud to bill old codes, and they will be checking into the places that are doing so. I don't know who to believe. I'd go somewhere else but we are in Michigan we need a very experienced surgeon, and they all seem to be in the bigger, coastal cities: California, Texas, Maryland, Florida. My husband is ready to throw in the towel and go back to his regular ns who refused to do a fusion and beg him.....we feel hopeless. We seem to be the only ones having this code problem, and unless we have the money upfront, the doctors office is NOT going to schedule it. Sorry, Dr. Geisler, I don't care how good you are, if I had to pay for it, we'd be on our way to Germany for superior care and less expense. My feeling is you need to move fast, try to get this done before the AMA, the hospitals or who-the-hell ever catches on and possibly follows suit like Rush Copley Hospital in Aurora Illinois and Dr. Fred Geisler and decide they will not accept an authorization with the wrong "code".
Sorry, this has turned into a vent more than advise and help to you. I just want you to be prepared for a fight. We've been fighting like hell and have gotten no where.
Best of luck to you,
Robin
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Old 04-21-2005, 07:04 PM
ESL ESL is offline
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sf.....somebody on this board posted a few days ago that some doctor in Texas was the most prolific ADR doc in the US....now you say its Dr. McAfee.......there really is only one right answer.....does anyone know this answer factually?????
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Old 04-21-2005, 07:14 PM
sfmcfar sfmcfar is offline
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Robin,

Sorry to hear of your troubles. Wonder if part of the reason is due to the fact that the L2-L3 disk replacement has not been approved by the FDA, whereas L4-L5 and L5-S1 has. Mine is at L5-S1 and Dr McAfee's office said I didn't even need a discogram because it was so obvious as to where the trouble was.

In answer to "who has done the most ADR surgery in the US" I doubt if there's a scoreboard. I suspect that most of the clinical trials docs have done a similar amount. I really don't care if Dr McAfee has done 150 and a guy in TX has done 160, as long as they're good at it. I do know that Dr McAfee did the first two-level replacement in the US and I have no doubt he's one of the best.

Stan
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Old 04-21-2005, 07:26 PM
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Harrison Harrison is offline
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Stan, Robin, thanks for sharing the latest on this complicated mess we call "managed care." I hope it gets better...

Dr. Geisler is a good man and a good doctor. If any of you have questions about US docs with experience, pls post your questions or topics in Arthroplasty Central.

PS: I was my doc's 14th ADR and I am doing great. He did perform well over 800 lumbar spinal procedures and started with the Charite' trial 5 years ago, so be careful what "metrics" you fixate on when making any doctor-related decision.
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Old 04-21-2005, 11:53 PM
Pat&Robin Pat&Robin is offline
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Stan, I don't believe that our insurance trouble has anything to do with the level Pat needs done, insurance hasn't even questioned that, they just simply don't have the code yet and the hospital won't schedule it without the right approval code. I did get a cost (just for kicks) if we were to pay for it: around $50,000 *choke* ahem....alrighty then, lol.
Harrison, thanks for the comment on Dr. Geisler. We feel very comfortable with him, just wondering why we had to get stuck with a doctor that won't budge on the insurance thing, actually they are blaming it on the hospital. I really don't know how many ADRs Dr. Geisler has done, but he didn't bat an eyelash at the L2/L3 level, only said it depended on the vascular surgeons opinion. I've contacted several other doctors that won't touch that level.
Harrison, who was your doctor?
Robin
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Old 04-22-2005, 10:48 AM
cavalib cavalib is offline
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Hi Stan,
I started seeing Dr. McAfee in March last year. I have heard that he has done the most ADR surgeries as well. I live in Florida and my doctor here suggested I see Dr. McAfee. Lucky for me I have family that lives in Maryland so it was convient for me. I saw Dr. McAfee again in December and he said I was a good candidate too for the ADR surgery. So I spoke with Carol and she set the surgery up for June 8th. Well my insurance denied my claim and Carol said she won't allow me to have the surgery done because of the expense. Well that's not for Carol to decide, I can pay out of pocket if I want. Anyway, ever since my insurance has denied my claim Dr. McAfee's office hasn't been very pleasant with me. It's like since my insurance isn't going to pay they are just going to brush me off. I have called them a few times to find out what I need to do to appeal the denial and they just keep telling me I need to call my insurance company and my insurance company keeps telling me it's the doctor's responsibility to do the appeal. I have CIGNA Open Access Plus through Orange County plubic schools, does that mean they might pay for me being a governemt employee?
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Old 04-22-2005, 07:55 PM
sfmcfar sfmcfar is offline
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Hi,

Sorry you had problems with McAfee's office. I have a feeling they're beaten down over the insuarnce fights and are tired of it, and I can't really blame them. As far as whose responsibility it to appeal, you should check your plan - they should have detailed instructions on the appeal process. As far as your being a Gov't employee, it just seemed to me that folks were having better luck getting approved that were Gov't employees. Also, check my most recent post on Federal employees, although that wouldn't apply to you.

Good luck,

-stan
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