Can we end insurance problems!!!!

[Dale S]

Hi to everyone who has been denied coverage by your insurance company,

What an education I've received these last two weeks since being denied adr coverage by BC. They use as their excuse that adr's are investigational. They sight studies that have shown that adr's are safe, effective and equivalent to fusion surgery.

If we are to successfully argue otherwise, it would seem to me that we need to use the very same ammunition. Currently, no studies show/prove that adr's are SUPERIOR to fusion. We can arm ourselves with doctor's reports and testimony as to their medical necessity, etc. but insurance companies come right back to that damned equivalency factor.

I would think separate studies need to be conducted for cervical, lumbar, single level, multi-level and for the Charite and the ProDisc individually. That's 6 studies each and for every new disc that obtains FDA approval in the future.

If studies showed that adr had long term superiority to fusion on mobility, pain relief, quality of life, fewer complications, less liklihood of affecting adjacent discs or any other medically relevent problem/side effect, then we could level the playing field and respond in the language they understand.

Until such studies are concluded I fear profit loving insurance companies will continue on their present course. Individual cases may be approved on a case by case basis but the denial rate is more than likely to remain high and our frustrations will continue.

I know absolutely nothing about how the medical community goes about such tasks. I would think those with the most to gain, the manufaturers and distributors, would be the initiators but could one then claim bias? Would doctors conduct such a study?

If there's anyone out there who has the power, influence or knowledge to get this started? I think it would bring us that much closer to acceptance.

I should also add that I don't claim to be right, only sensible. I could be way off base too!

Food for thought - Dale

[ans]

D: I guess the question is if ADR is better than fusion in the long-run. I think the Europeans kinda screwed the pooch in not having the best planned studies - but I'm just an amateur. Now we hear reports of facet joint problems post-ADR, an inability to precisely diagnose exactly what drives "discogenic" pain, and the harsh fact that once an ADR is in you, revision surgery thru a fusion conversion is no given.

Yet, there's people like Mark, Alistair, Richard, more who are absolute success stories.

I think it's gonna take a while for good data to emerge. And this hurts people like yourself in agony.

[Brad]

Dale S
In my opinion, it is the responsibility of J&J, makers of the disc, to get this done. This would be market driven and they have the money to do it. Not only are we not getting approved, they are not selling disc's. I think that this is where the pressure will come. Also, when the Prodisc gets approved it will create more natural pressure on the insurance companies.

Just my thoughts....
Brad