where do i start?

[luckyshot]

I need help, advice, or anything some of you might offer.

been having back pain progressively worse for the last 3 years. I have to fix it now and I want my active lifestyle back. I was sent from the neurosurgeons in KY to Cleveland Clinic. I was then told that I needed surgical intervention at L4 L5 and L5 S1.

Dr. McLain in Cleveland told me about the difference in ADR vs fusion. I immediately decided to have ADR at both levels. But, he said my insurance would not pay for it, they might would pay for a hybrid. I am determined to get both levels fixed with ADR. He didn't even submit the CPT codes to Aetna. Instead I drove 400 miles back home and his office called and told me that this particular CPT code for a two level ADR does not exist. I am no doctor, but from what I've come up with 22857+0163T should do the trick. If they don't even know what to ask the insurance company for, I sure don't want them doing the operation anyway.

Going overseas for me and paying out of pocket is out of the question. My Aetna policy states that it pays for nothing elective outside the US.

I've been sent home from a very physical job because they have no "light duty" light enough per my doctors specs. So, I have about 5 more weeks short term disability before I go unpaid.

I contacted Texas Back Institute by voice mail and by e-mail and have had no response for two weeks now.

Possibilities?
-a doctor in the US who might do a two level ADR within Aetna's network,
-a letter of commitment to pay overseas from Aetna,
-precedents or some documentation of Aetna covering 2 levels in the US.

I really don't know what I need or where to go. I've got MRI, Xray, and CT scans, as well as all the radiology reports that go with them, on hand and ready to ship. I never even had a Primary Care Physician until all this started a couple months ago. ANY advice will be appreciated.

Thanks so much.
luckyshot

[NJ Gene]

Dear Luckyshot,

Texas Back Institute, besides being one of the best institutions in the U.S. for ADR, is known to also be one of the best ones in assisting patients with insurance appeals. I think you need to be persistent (ask for the main operator to transfer you to Dr Jack Zigler's office) and insist on speaking with a live person. I have no doubt that they will know the insurance codes. It's only been a recent development where the FDA has allowed 2-level fusion in the U.S. Many insurance policies will still consider it "experimental" and will not cover it. Also know that a hybrid is not necessarily a bad thing (much better than a 2-level fusion from what I've heard). I had a fusion in my lumbar spine at L5/S1 three years ago and I feel great (with respect to the lumbar spine). If you look at my signature, I don't even mention this because most of my issues have been cervical.

BTW, it's highly unlikely that your policy will cover anything if you go overseas. The only people who have some luck with overseas coverage are those with a Blue Cross/Blue Shield international plan. Furthermore, they generally don't get pre-approval. Those that go overseas usually have been in severe pain for a very long time and are prepared to spend a minimum of $30k to $40k out-of-pocket with little to no expectation of reimbursement. Don't get me wrong, most people who have gone overseas have had excellent results. However, it does come with a price. Every cloud has a silver lining though. To the extent that your medical costs exceed 10% of your adjusted gross income, they can be taken as a deduction on schedule A of your tax return (regardless of whether of your expenditures are in the U.S. or abroad).

If you need further information, don't hesitate to ask.

Good luck!!

Gene

[luckyshot]

gene,

thanks so much for the quick reply. I will be calling texas again with much more motivation, as I just got all my record in from Cleveland. I am making copies of the imaging cds right now.

also thanks for letting me know about the tax deductions. hopefully it won't come to that. In case I do go overseas, is there any kind of tax rule when your medical expenses exceed 100% of your annual income? lol

I have done quit a bit of research on the hybrid, but I am just 27 with a lot of things I wanna do before I slow down. I am 100% healthy and fit I would much rather fight for the 2 level ADR now while it matters the most to me. I got married right before my back started hurting and now I have the coolest 9 month old boy ever. I just want them to have the real me. I wanna teach him to ride four wheelers and hunt and hike and work. im just not up to it and a fusion at any level scares me. Right now me and my boy play in the floor and we both have to crawl to the couch and pull up....its cute when he does it. I am so used to being really really active, my whole family is healthy and active and tough, my 73 yr old grandpa can do more than I can at the moment. I just can't give up on losing ANY of my mobility yet.

[NJ Gene]

Luckyshot,

I'm happy to be of help. Just so you understand, if it weren't for my neck healing from recent cervical surgery, I could play tackle football according to my surgeon. Here is a link to his website: New York City Minimally Invasive Spine Surgeon | Daveed D. Frazier, MD If you look at the pain page, he has a link for a free MRI review. While he does not personally perform ADR, he is in touch with some of the first surgeons who have done so in the U.S. I believe he is in the Baltimore, MD area. Tell him everything that you told me so far. I'll give you my full name in a PM, so you can tell him that I told you to contact him. Just so you know, my surgeon happens to be African American. He is considered to be one of the top 10 of African American spine surgeons in the U.S. He attended Harvard Medical School and did his residency at Mass General Hospital (Harvard's main teaching hospital).

I was set on doing ADR for my last surgery. I had flight reservations booked to Germany (not paid though). He talked me out of going abroad. He did offer me the option of ADR through his colleague in Baltimore, but convinced me that it was not necessary in my particular case. It didn't take much convincing for me not to spend $40K out of pocket.

BTW, if the surgery costs more than your annual salary in out-of-pocket expenses, you can ultimately reduce your tax liability down to zero for your Federal and State returns (you can't go into the negative unfortunately) That means that everything you had withheld from your job would be refunded to you.

Gene

[TPatti]

NY Genes has given you a lot of helpful advice! I also do not want a fusion because of limitations and adjacent disc degeneration, I ultimately would of ended up with a 3 level fusion. I am scheduled for 3 level lumbar(S1-L3) on 7/16 with Dr. Bierstedt. I am 42, own a small residential remodeling, am(was) a triathlete and want to be active again.

[twowheelyankee]

I have to disagree with gene being a patient of TBI. They did none of the leg work during my appeal. They didn't raise one finger. I had to provide all the evidence, conservative treatment evidence, and please my case, which I just won last week. I have had to call2 or 3 times, send emails just to get a simple response from the office. The office claims to be under-staffed, but refuse to hire. Considering they quoted me a cash price of $42K you think they could afford another staff member or two.

I don't question the doctor's technical ability but do take issue with the way the office is run. I had to ask and demand a bone density and discogram. Those issues were ignored because TBI said it was a waste of time because BCBS would not approve ADR. Well, they were wrong.

While I like being in control of my own destiny, I would have appreciated some help from an office that has a wealth of knowledge with respect to medical topics and techniques.

In addition, I asked about the prodisc-O for lumbar and was answered with a ridiculous.. "I don't think its approved in the US."

Is that the best an ADR office has... "I don't think". I am pretty upset with TBI right now. However, if I were to switch, I would have to go through the appeal process again. It wasn't painful but it was very time consuming.

Hope this addresses your concern with TBI. It does little for your actual condition, but it is best to be informed with knowledge.....

Take care,
Jim

[NJ Gene]

Luckyshot,

I have heard from many other patients than twowheelyankee on this board who had better experiences with TBI. However, I have no doubt that he had a bad one and that you should explore other places/physicans. I think contacting my surgeon, as I indicated in my last post, would be a good place to start. Also, if you go onto the AIMIS Spine site at Locate a Surgeon | AIMIS Spine | Minimally Invasive Spine Surgery many of these surgeons do ADR. What I strongly advise against is going to Cyprus to be operated on. In Cyprus, these U.S. doctors are shielded from malpractice. For this reason, they often perform risky procedures that don't fall under FDA guidelines.

I would check out your plan, see if any the doctors listed on this site are in it, then Google them to check their credentials. A great site to check out any physician is Doctor Reviews and Doctor Ratings | Compare & Find Doctors | Vitals It's applies to all U.S. physicians. It gives information on where they trained, the various hospitals with which they are affiliated, and comments from other patients.

I hope this helps.

Gene

[luckyshot]

texas back must have some mind readers on staff.

last Friday, as I was about to call them, my phone rang and it was Dr. Zigler's nurse, Sheryl. the nicest and most helpful person that I have talked to at any facility. she told me exactly where to send my records and even gave me her cell number and personal email.

my records arrived at TBI this past Monday. Today is Friday and I hadn't heard a thing. As I sat down just now to give her a call, my phone rang. her again. this time she told me that dr zigler was out of the country this week, but she had informed him of my records arriving and he is going to look at them on Monday. she said she would call me no later than Tuesday with info on his opinion.

still don't have a clue if anything is really goin my way...but right now im excited and very happy with TBI!!!

[NJ Gene]

Luckyshot,

I'm glad to hear that TBI is returning your calls. For your interest, Twowheelyankee told me in another thread that he finally got pre-approval with his insurance, so I am pretty sure that he'll will be getting his ADR surgery done at TBI. Twowheel, I'm sure you'll be reading this, so you can confirm.

Good luck Lucky (no pun intended) with the remainder of the process.

Gene

[zenmunk]

TPatti,

What made you choose Dr. Bierstedt?

Thanks,

z