Aetna Insurance Denial: treatment of degenerative disc disease with spinal fusion "experimental"

[bigdogchief76]

Hello all -

My name is Matt Brown.

I'll cut right to the chase. I am hoping to hear opinions/insight with my current health problems related to my disc at the L5-S1 area.

I've had LBP for 3 1/2 years. The initial problem caused me to have serious tingling up and down my right side (which I now know as sciatica). However, I did not have a MRI done as the symptoms subsided after taking it easy in bed for 3 or 4 days. That was in the fall of 2005.

Off and on between Jan 2006 - April 2009 I had continual battles with serious lower back problems. I always assumed it was simply "aging" and not anything more serious.

In April of 2009, I woke up one morning and was unable to walk without a great deal of pain in the right leg, from the toes all the way up to the beautiful right cheek of mine

I had MRI which showed disc bulge in L5-S1 with moderate disc degeneration. I had 2 steroid epidurals, which helped with the pain and then extensive PT for the rest of the summer/early fall of 2009. My back seemed better, but I would still have flair ups of extensive pain whenever I did physical labor or tried to play with my then 2 yr old daughter.

We moved to Wichita KS and bought a house in Jun 2010. I got all of the inside painting done before the furniture arrived. Shortly after (mid July) I started noticing the burning/tingling sensation in the right leg. I tried all of my PT exercises, but it just got worse and worse. I saw back surgeon in August, who then wanted me to try once again the non-operative methods again. I concurred since it seemed to help last time. I did not want surgery in August.

I had MRI that showed bulge in L5-S1 with now aggressive degeneration. I had 2 steriod/epidurals in Oct which did nothing to ease the pain. I had about 6 -7 PT appointments that I attended, but had to stop about 15 minutes in because of the severity of the pain. I'm a tough SOB, but, this pain is the worst thing I can imagine.

I had disco-gram on 21 Nov. This showed the disc at L5-S1 to be in bad shape. I apologize as I do not know the grade at which it was rated; I know my back surgeon used "ruptured" in our consultation. On Nov 24th, I opted for fusion of the L5-S1 vertebrae. My pain is so severe that I felt that it was the best option.

Yesterday evening my insurance, Aetna, denied my request for this surgery. Aetna does not allow for fusion surgery for DDD as they deem it to be "...experimental and investigational for degenerative disc disease and all other indications not listed above as medically necessary because of insufficient evidence of its effectiveness for these indications."

My surgeon already had a "peer to peer" review with an Aetna doctor. Kicker: the doctor at Aetna was a OB doctor. It seems that Aetna utilizes an "on call" method for initial peer to peer reviews. I'm so glad that the OB doctor deemed it unnecessary still. My back surgeon told the OB doctor he was sorry he wasted his time, because he DEFINITELY wasted his.

Well my back surgeon office has already submitted the initial appeal on my behalf. They got all of my data faxed as of 1430 CST today. I'm grateful for their help, because they could easily say "So sorry Charlie"
So, here's a million dollar question: Aetna will authorize the following:

"Aetna considers FDA-approved prosthetic intervertebral discs (e.g., the Charite Artificial Disc, and the ProDisc-L Total Disc Replacement) medically necessary for spinal arthroplasty in skeletally mature persons with symptomatic (e.g., back and/or leg pain) lumbosacral degenerative disc disease confirmed by radiographic studies (e.g., CT, MRI, x-rays) at one level from L3 to S1, and who have failed at least 6 months of conservative management."

but will not authorize a lumbar fusion. Make sense to anyone?

Should I begin a search in Wichita for a doctor that will do a TDR, or should I stick to my guns with getting the fusion approved?

Any suggestions for the appeal?

I appreciate any feedback and look forward to the support during this difficult period of my life.

Thanks,
MB

[bigdogchief76]

Sorry, I did a signature, but, forgot that oh so important "Save"

So here we go

[Justin]

Hey Matt,

Welcome to the Spine Patient Society.

I'm sorry that you are finding yourself in this mess with Aetna. How are you feeling by the way? Your denial for spinal fusion is a "new" tactic that is being used by insurance companies in recent months. See this thread: Spine Patient Society Plays a Pivotal Role in Recent Uproar Regarding the New North Carolina BC/BS Policy on Spinal Fusion Coverage.

Is your surgeon a Member of the AAOS (American Academy of Orthopaedic Surgeons)
or the AANS (American Association of Neurological Surgeons)?

If so, have him contact his respective Society and ask what is being done / how surgeons are moving forward with these recent insurance battles (insurance companies denying spinal fusion for degenerative disc disease, etc.). I know that both Societies, and many others, are fighting this nonsense head-on.

Please let me know if there's any way the Spine Patient Society can help. Good luck!

[bigdogchief76]

Hey Matt,

How are you feeling by the way?

Roller coaster of emotions since I found out denial yesterday evening. Basically been up all night and day doing serious intelligence gathering. Back pain? Serious. Hurts like a firecracker up and down my right leg. Pain in the back is severe. I've learned to live like this for a while, so hard to estimate.

Is your surgeon a Member of the AAOS (American Academy of Orthopedic Surgeons)
or the AANS (American Association of Neurological Surgeons)?

My surgeon is Dr Michael Chang and he is indeed an AAOS member. Other vitals:
Degree: Mayo Medical School — Rochester, MN
Residency: (Orthopedic Surgery) Mayo Graduate School of Medicine — Rochester, MN
Fellowship: (Orthopedic Spine Surgery) University of California — San Diego, San Diego, CA
Board Certified: American Board of Orthopedic Surgery

His PA is a life long friend of mine. So I have some advocates in the office.

The office put in the "official" appeal for me. I'm not buying that it's going to work. I'm smart enough to know that I need to get my own personal appeal up and going; it's something I am working on. However, I believe that even my own appeal will be shot down.

I will have Dr Chang contact his society and see how to win this battle.

After seeing that Aetna allows ADR/TDR it leads me to believe that they have been "bought out" if you will by the two FDA approved ADR companies. Probably a conspiracy theory in there, but, still might be something....

I appreciate all that I have read on here thus far. I want to make the right decision and hopefully can get this resolved.

MB

[klh]

Matt -

So sorry to hear of your back problems, and insurance too. Insurance seems to be half the problem for most back patients unfortunately. However, from my experience with my own back issues (13 yrs now), and everything I have researched and read on forums like these, I am amazed, and happy, to hear you got approved for ADR. That is almost rare these days as being experimental. Mine is also L5-S1 and I have tried almost all types of alternative therapies, injections, meds, you name it. I am planning for my own ADR next year. But maybe this is a blessing in disguise for you.
Not only did you get approved for an ADR, but for most outcomes and research I have read on fusion vs ADR, if you are a good candidate and have few co-morbidities, ADR has a good outcome ratio. It leaves more mobility and flexibility, less chance of adjacent disc failure, faster recovery, etc ...
Reading your post, your doc has excellent educational credentials. The only thing I would do is ask him about his ADR experience. How many has he done, with what discs (Charite', ProDisc, etc ...), what is his success rate? problems he sees? their recovery program and after care follow-up? etc ... (By the way, Charite' is now the In-Motion disc. See --> Orthopedics This Week - Spine ).

Much of the research I have done over the years has showed me that many of the non-successful back surgeries had more to do with other factors than the disc itself. Many people are not the best qualified candidates and/or have other issues going on, and don't recover well. There are many risks and complications to consider, but if this is your best hope, go for it. Do all the best research you can, ask all the right questions, get the best qualified doc/hospital to do it (even if you have to go elsewhere), and so on.

Either way, congratulations on ADR approval (and fusion approval hopefully), but I still think this is a blessing in disguise!

Ken

[KBear]

Welcome to the forum and sorry you are having insurance issues. Insurance definitely seems to be the number 1 roadblock for most of us. A year ago I had never heard of an insurer denying fusion, as that was their go to surgery. But lately, I am hearing more and more stories of fusion denial, though I've never heard of them offering ADR instead. I had to read that 3 times to make sure I was reading it correctly. Seems like if you apply for ADR you are denied and told fusion is best, but is you start with fusion it could go either way. If you and your doctor feel fusion is best, then I would fight for it. At L5/S1 there isn't much movement to start with, so if it were me, I'd fuse that level. I've heard of people getting ADR's there and it being fine, so it's really up to you and your doctor. Best of Luck, Kathy

[bigdogchief76]

Hi Kathy (et. al that might ask)

I haven't applied for ADR. I was simply researching AETNA's back surgery policies and saw that the ADR is something that is approved for DDD; fusion is denied.

That makes no sense to me at all. How can a surgery like fusion (a gold standard at one point) be considered experimental with 40+ years of success, yet a procedure like ADR, which is still infantile in nature within the USA, be ok for fixing a problematic disc???? Are the insurance companies on pain meds?? lol

I am at a serious crossroads on what to do. ADR or fusion? Research, research, research is all I have ahead of me. I think I plan on making a appointment with one of the neuro's here in Wichita that do the ADR procedure; see what he has to offer and say. I also want to hear Dr. Chang's advice as well.

I salute a person like yourself Kathy; you have been through a lot (haven't been stalking, just reading these forums)

I pray that your pregnancy will be successful and that you and the little one with be protected throughout.

MB

[KBear]

Hi Kathy (et. al that might ask)

I haven't applied for ADR. I was simply researching AETNA's back surgery policies and saw that the ADR is something that is approved for DDD; fusion is denied.

That makes no sense to me at all. How can a surgery like fusion (a gold standard at one point) be considered experimental with 40+ years of success, yet a procedure like ADR, which is still infantile in nature within the USA, be ok for fixing a problematic disc???? Are the insurance companies on pain meds?? lol

I am at a serious crossroads on what to do. ADR or fusion? Research, research, research is all I have ahead of me. I think I plan on making a appointment with one of the neuro's here in Wichita that do the ADR procedure; see what he has to offer and say. I also want to hear Dr. Chang's advice as well.

I salute a person like yourself Kathy; you have been through a lot (haven't been stalking, just reading these forums)

I pray that your pregnancy will be successful and that you and the little one with be protected throughout.

MB

Thanks for the explanation, my brain isn't always on board with me... Thanks for the kind words.

[rgutshall]

I actually joined this site because I was looking for others that had been denied lumbar fusions. It makes no sense to me that its now being considered "experimental". Two years ago, my insurance company, also Aetna approved a TWO LEVEL ADR, but now won't approve the fusion in 2011. I am awaiting the decision on my first level appeal. So we'll see.

[laid up doc]

Aetna considers fusion for DDD experimental... you have to have I believe grade III spondylolisthesis even, to have fusion approved.

They probably would have not ended up covering a 2 level ADR in the US, since the Prodisc is not FDA approved for such. If you check their policy guidelines, they do state this.

Part of the reason I went overseas... fusion scared me b/c of my SI joints and age anyway. Probably turned out for the best in my case.

Have you consulted w/ Boeree, Clavel, Pimenta, etc???