Dr. Paul C. McAfee, Maryland, Anyone have any experience with this Doctor??

[mccauleyjw]

Hi All,

I am seeking a Doctor that is "Pro" Cervical Artificial Disc Replacement in the Washington DC area. Basically, I need a doctor that recommends Artificial Disc Replacement over Fusion to fight my insurance company "CareFirst BlueCross Approve Nothing".

While searching SPS, I found a list of doctors that do Artificial Disc Replacement by state. Paul C. McAfee was listed in Maryland about a couple hours from my house.

Does anyone have any experience with Dr. Paul McAfee? Does he recommend Artificial Disc Replacement over Fusion? Does he help with convincing insurance companies that consider ADR experimental? Is he a good surgeon?

Thanks,

John

[Justin]

Hi All,

I am seeking a Doctor that is "Pro" Cervical Artificial Disc Replacement in the Washington DC area. Basically, I need a doctor that recommends Artificial Disc Replacement over Fusion to fight my insurance company "CareFirst BlueCross Approve Nothing".

While searching SPS, I found a list of doctors that do Artificial Disc Replacement by state. Paul C. McAfee was listed in Maryland about a couple hours from my house.

Does anyone have any experience with Dr. Paul McAfee? Does he recommend Artificial Disc Replacement over Fusion? Does he help with convincing insurance companies that consider ADR experimental? Is he a good surgeon?

Thanks,

John

Dr. McAfee is a well-regarded spine surgeon. He was instrumental in the early Charite ADR trials in the United States.

Your second question: "does he recommend artificial disc replacement over fusion?," does not have a simple answer. Of course, we all have unique pathology and if an artificial disc is contraindicated for a Spine Patient, you'll be hard pressed to find a surgeon that will operate on you. I wouldn't want a surgeon blindly recommending artificial disc replacement surgery over spinal fusion, especially if it was not the best procedure for my situation. Spinal fusion is a very good procedure and is often the best procedure for many properly selected patients. Placing ADR devices in Spine Patients with gross contraindications have resulted in some very devastating cases.

[mccauleyjw]

Hey Justin,

Again, Thank you for your reply.

So far, I have only seen one Neurosurgeon, Dr. Charles Riedel, in March 2011.
At that time Dr. Riedel recommended two procedures: Fusion or Artificial Cevical Disc Replacement.
Dr. Riedel stated that Fusion is not as bad as it use to be. However, it can can excessive wear on the adjacent discs.

As far as ADR, Dr. Riedel stated that the recovery times are much better and there is better motion. However, he also stated that it is a newer technology and the long term effects are still unknown. He also stated that Artificial Discs will cause a "Black Hole" in any future MRIs.

Anyway, Dr. Riedel told me to think about what I want. I went home and did a lot of research. After waiting 20 years for newer technology, there is no question in my mind that ADR is the way to go.

About a week later, I called his office and Adrienne Blackstone picked up and ask me if I wanted to schedule surgery. I stated that I had some questions regarding ADR. Adrienne stated that she would have someone call me.

Several days later, Wendy Cohen, PA called me. I asked her how many Fusions has Dr. Riedel done and how many ADRs he has done. Wendy stated the the Doctor has done over 1000 Fusions and about a dozen ADR's. I asked her what type of disc that Dr Riedel use in ADR. She stated the Prestige.

I then told her, based on what I have read, the my insurance plan my not cover ADR. At that time, she told me that they would submit the paperwork for approval and we should her something in 3 to 6 weeks.

After six weeks had passed, I called the office again and spoke to Adrienne. She again asked if I wanted to schedule surgery. I stated that I was calling to see if the ADR was pre-approved by insurance plan. She quickly told me that I have to call my insurance company. I then tried to explain that Wendy told me that the doctor's office was going to do this. She stated that Wendy does not do that, I have to. I then asked why Wendy would tell me that the doctor's office would do that. Adrienne again stated that I have to call my insurance company. I explained that I don't know what to tell my insurance company. She told me to tell my insurance company that I wanted a Cervical Artificial Disc Replacement. During this conversation, I found Adrienne to be rude and I just told her to have Wendy give me a call. I never got a call back from the doctor's office.

I tried to call Carefirst BlueCross BlueShield and was on hold. So, I went to my online account and asked if Cervical Artificial Disc Replacement was covered via their messaging system. Well, after several attempts over two weeks, my messages never went through. They just kept landing in my inbox. After several hours with BCBS tech support, they found the problem in their website and corrected it. CareFirst later replied that they would need the procedure code for ADR. Arrgggggg.

So, I called the doctor's office to get the code. Several days later they called and gave me the code and I submitted the code (22856) to CareFirst.

CareFirst later replied: "Thank you for your inquiry. We regret to inform you that Cervical Vertebral Disc Replacement is not a covered benefit under your contract per our medical policy. You may have your provider submit an authorization for this and once this denies, you can appeal this. Please have your provider contact our Utilization Management Department at 1-800-443-5434." I faxed this to Dr. Riedel stating that I was in a loop and needed help.

Well, about a week later, Adrienne called me and in a rude manner ask me what I wanted. I explained that I needed help getting ADR pre-approved. She quickly stated that Dr. Riedel recommended two procedures, ADR or Fusion. She then stated that since my plan does not cover ADR, I have to get the Fusion. GAME OVER. I then told her that I think it is my best interest to find another doctor and get an attorney.

Although Dr. Riedel maybe a great surgeon, it appears that he is more experienced with Fusions than ADRs. His office staff makes it impossible to speak to the doctor. Finally, they refuse to provide any assistance or submit any paperwork for pre-approval. I am not going to let an Office Manager tell me that my only choice is Fusion because that are not willing to deal with the insurance company.

It has been determined that I am a good candidate for ADR. All I need is a good Surgeon that believes ADR is better than Fusion and is willing to submit the appropriate paperwork recommending the procedure. I am quite sure that CareFirst BlueCross Blueshield will deny the procedure. However, I have an Attorney that will take it from there.

I have found SPS to be a great source for info (Thanks to All) and this is where I got Dr. McAfee's name from. It appears that Dr. McAfee supports ADR over Fusion, but wanted to know if anyone else has had any experience with Dr. McAfee supporting that he does support ADR over Fusion. My Attorney has warned me about seeing too many doctors regarding this situation for CareFirst may accuse me of manipulating the system in my favor.

Again, thanks to all here. All my Attorney and I need is a good doctor in our corner.

John

[runagain]

John,

I am sorry you went through all this. The doctor's office appears not to want to deal with insurance companies. It is kind of weird. The doctors pretty much know what insurance companies will cover ADR without too much trouble, but others (ins. companies) are maybe or maybe not. You cannot tell until you go through the process of appeals after the denials.
About the same time I had surgery, I had a friend I met on-line, who called BC every day, was very proactive in trying to get the surgery and was approved for lumbar ADR, but even with that she told me they gave her a hassle about what they were willing to pay after surgery.

The internet is our best offense or defense (depending on how you look at it) against the insurance companies.

Some of the things you asked for the doctor's office to do and they did not respond in kind are things you can find on the internet. Like the code for cervical ADR (prestige), it is the same for all doctors as far as I know.

Also, it is up to the doctor's office to fax or e-mail or whatever, the request for surgery. This is the way it is done in my doctor's office, they do the request for surgery, however, after the denial, they submitted an appeal in my case. I also did an appeal along with theirs.
It might help you to read about laurie, the insurance warrior. Her books/CD were helpful for me.
But if you are going to fight your insurance company, be ready to get down in the trenches. I went through this twice and it took a lot of work on my behalf and on the first go-around, I had an attorney who did much of nothing. It took a lot of effort to get an attorney because there were not too many who wanted to take my case since I did not have an individual policy, rather I had a group policy.

If you go to a doctor and he/she says you are not a candidate for this surgery, you have to look at what they say and look at all your options.
Cervical ADR has had good results, just looking at all the info on the internet about the different trials and also the information about ADRs in the rest of the world. The prime reason for my doctor wanting an ADR (lumbar) was the fact that the studies showed that there was less adjacent disease at other levels with the ADR.

I still believe that getting a top-notch surgeon, who you can communicate with, is more important than what surgery you get. Still surgery is not something that you take easily. When it is life-threatening or there is the possibility of nerve damage or paralysis, or you do not have a life because of the pain, then I would consider surgery.

This is my two cents. Got to go. Good luck,

R

[mccauleyjw]

Hi Runagain,

Thank you for your comments. Yes, it does appears strange that Dr. Riedel's office does not want to deal with the insurance company. However, Dr. Riedel is very popular. It took me eight weeks to see him.

The problem with Dr. Riedel is that he appears to favor fusion over ADR. CareFirst will cover fusion, but will not cover ADR. Since he is so popular, I guess his office can afford to let me go instead of filing paperwork for ADR. In other words, his office is too busy to deal with insurance companies. Again, Dr. Riedel maybe a great surgeon, but he appears old school and dealing with his staff in next to impossible.

I do have a good attorney that specializes with health insurance and I have individiual coverage. I just need a doctor that is pro-ADR to submit the original request. Then I can give the ball to my attorney.

Thanks,

John

[runagain]

Yes,

John. Individual policy helps a lot.
As for the dr, who knows. It could be that his front office is not so good or whatever. One thing I found is if you write a letter to the doctor, you might get a call back from the doctor.
You want a doctor that does both ADR and fusion, so when the doc makes the call for fusion or ADR, you know that they are looking at both modalities.
Tread carefully, some doctors do not like lawyers and some have departments devoted to them. You might have more leverage against the insurance company with an individual policy, because they know that a lawyer that is good will take the case against them.
Still, check out Laurie. Info about her is on here.
I educated myself a lot in my fight against ins. company. Even got some press, did not help. But don't give up the fight if the doc you get says ADR is better for you than fusion.

R

[mccauleyjw]

Well,

Since nobody could provide any personal experience on Dr. Paul McAfee, I took one for the team and drove a couple hours and saw him yesterday.

The good news: I liked him and he is Pro-ADR. He recommended the ProDisc-C. I found his staff very helpful and they are willing to submit the intial paperwork along with an appeal to CareFirst BlueCross Blueshield.

The bad news: Well, this is not against Dr. McAfee or his staff. After looking at my MRI, Dr. McAfee recommended that both my C5-C6 and C6-C7 be replaced. Although the C5-C6 is not as bad the C6-C7, it is damaged. Dr. McAfee suggested, "While we are in there, get them both done or I will have to come back down the road." Yes, this makes perfect sense, but his staff said it is most unlikely to get two disc replacements covered by CareFirst. I already know that I am going to have to fight for one.

Anyway, I feel really confident with Dr. McAfee and glad that I made the trip. I liked that the staff presented scenerios regarding the insurance company. For example: They asked what would I want if CareFirst denied everything or only approved one disc replacement? There are options on the table, but first I will try to get CareFirst to pre-approve a two disk replacement.

Sure, I believe this is going to be an uphill battle. However, my attorney and I now now have someone in our corner that is willing to get the ball rolling with my insurance company.

IMPORTANT INFORMATION for anyone trying to get their insurance company to approve a ProDisc-C Total Disc Replacement:::: Synthes Spine, (maker of ProDisc), has a Patient Assistance Hotline. I called them and asked what services thay offered. I was told that they will help in every stage regarding insurance, appeals, etc. They have a third party group of legal and insurance specialists to help with your fight.

Synthes ProDisc


Cheers,

John