ADR vs Fusion

[bigdogchief76]

So, I gave my story in my intro.

Give it to me straight folks. I want to know people's opinion on my situation. Hearing different views will help me make the decision, in conjunction with my back surgeon's opinion. I value both sides of the story.

Fusion is being denied via the insurance company. Formal appeal has been started with it as of Friday the 10 Dec 2010.

Insurance company will (according to their policy and if the patient meets the criteria) pay for the ADR. I've looked at the policy until I'm blue in the face, and I believe my condition fits what they say meets their criteria (it's crazy that the insurance company dictates what I can do...frustrating)

The AD has to be approved by the FDA.

Cuss and discuss...what do you all think??

[KBear]

Cuss and discuss...what do you all think??

Haha, you made me laugh. Honestly, I would go for the fusion, being that it's the lowest level. In my opinion, that leaves you open if in the future you needed more spine surgery to get ADR(s) above that level. Unfortunately, the nature of spine problems is that eventually most of us are going to have more spine problems. Even though ADR supposedly slows/ stops degeneration, there are many who had ADR and then needed or do need more surgery on adjacent levels because of continued degeneration.

The other questions that come to my mind regarding why your doctor recommended fusion in the first place are: 1) Did he see something on your imaging that led him to believe you were not a good candidate for ADR? (ie. degenerated facet joints) 2) Did he say fusion because he only does fusion? 3) Is there some other reason why he felt it was better for you? Both are major operations and all pros and cons should be weighed before going forward. I would also suggest getting a couple of more opinions, even if you have zero intention of using anyone else, they may see something or bring up some other point worth considering.

[bigdogchief76]

The other questions that come to my mind regarding why your doctor recommended fusion in the first place

I talked with the surgeon's PA today (who is a great friend of mine). He seems to think (for better of worse) that potentially he does not mention ADR because of past denials of insurance claims. He's a fusion first type of doctor, with a long proven track record of successful fusion's. Now that insurance companies seem to be flip-flopping on approving ADR over fusion (I've read some of the medical discussions that AETNA quoted, and quite frankly, based off stats, I have to concur; not that I will EVER give AETNA the benefit of knowing that) I have to believe that he might begin doing ADRs.

I'll know tomorrow or Tuesday on what my surgeon thinks.

[Justin]

If I was in your shoes with only L5-S1 needing surgical attention, I would have a fusion. Just my .

Good luck!

[ajj1001]

I'd get a couple more medical opinions and check out how likely you are to get any problems at higher levels.

[bigdogchief76]

So spoke with Dr Chang this afternoon. He does not feel that ADR's are as effective for my particular condition (one level aggressive DDD, etc.)

I've spoken with some other doctors as well, and all are concurrent with single level fusion. Not one said ADR.

Sooooo.....it's time to wait patiently on the Lord and let the appeal process work. (If you aren't religious, then I'm waiting patiently on the insurance company... )

Office did get in a lengthy letter from Dr Chang on an Urgent Care Appeal that sounds like can be used for my case. I also submitted my heart-felt request in conjunction with the appeal.

Thanks for your feedback....

MB

[KBear]

Matt,
That makes it a lot easier when all the doctors agree on the course of treatment. I'll be praying you get approval soon. BTW- You have a beautiful family.

[Justin]

Good luck with everything!

[Cindylou]

Matt, If I were you I would also get a fusion at L5-S1, and that's exactly what I did, in fact. 2.5 years ago, July 08. I wouldn't hesitate for a second on that one. It has served me well. Again, just my 2 cents. Nice to see your new "avatar" up......Family. And one lovely one, at that. Cindylou

[bigdogchief76]

So I'm working up all the logistics to see a neurosurgeon in Wichita.

We have a Spine Clinic which is one of the better ones in the Great Plains area.

They have this written on their website, which I am going to get some more detailed answers about, but, it's interesting none the less. If I end up going with one of the doctors from this clinic, the facilities are FAR better then the hospital that I have to use under my plan for in-network.

"If your insurance has “out of network” benefits, you may use KSH (Kansas Spine Hospital) without paying out-of-network rates. You will still be responsible for your deductible, co-pay and co-insurance, the same as if you were using a contracting hospital"

Does this sound crazy????

I am going to discuss the ADR, simply to have an alternative planned out if this fusion procedure gets continually denied by AETNA. Plus, they might have some more insight into what's going on with the disc at the L5-S1. I trust my current spine doc, but, I want some more opinions.

Wish I could just get fixed sooner than later, but, will be patient with this.

Thanks for all of your feedback.

MB