BCBS Companies Covering ADR

[Researcher]

Today, I called the Synthes Spine Patient Assistance Line to see what they could tell me about the current status of insurance coverage for cervical ADR. Since I have BCBS, I was most interested in BCBS. The representative said that the following ten BCBS companies currently have a positive cervical ADR coverage policy.

BCBS North Dakota
BCBS Illinois
BCBS Montana
BCBS New Mexico
BCBS Oklahoma
BCBS South Carolina
BCBS Texas
BCBS West Virginia
BCBS Highmark Pennsylvania
BCBS Horizon New Jersey

This is consistent with the current Spine Institute cervical list at http://www.rmsas.com/documents/Payor...geCervical.pdf which has been posted elsewhere in the past. For insurers with coverage of lumbar ADR see http://www.rmsas.com/documents/Payor...rageLumbar.pdf.

"Positive ADR Coverage" by these groups is restricted to the current FDA limitation of one level. If you are interested in learning more about insurance coverage for ADR with an insurance company besides BCBS or more details on one of the BCBS companies, I would call the Synthese hotline at 1-800-895-7764. I would not mention anything about multi-level ADR or the conversation will become immediately challenging. Even if you are not currently a Prodisc patient (I am not), they are still helpful. I was polite and truthful and they provided me with some very good information and invited me to call back anytime I had additional questions.

Phil

[Justin]

Phil, thank you for posting this information. It should be most helpful to those that frequent the Spine Patient Society Forums.

[Researcher]

For those Florida patients, as of 11/15/2010, BCBS of Florida has a conditionally positive ADR policy. It is a copyrighted document, so I can't copy it verbatim, but here is the essence.

Must meet ALL of the following:

• Non-discogenic pain sources have been excluded
• Symptoms of cervical radiculopathy and/or myelopathy, with or without axial neck pain
• Cervical degenerative disc disease (DDD) at one level from C3 – C7
• Compressive lesion is documented by MRI, CT or myelography
• Failed non-operative treatment, for at least six (6) weeks, including ALL of the following:
  
  • Medications (e.g., NSAIDS, unless contraindicated)
  • Activity modification, traction therapy, physical therapy or injection therapy
  • 18 to 65 years of age

Not covered for ANY of the following conditions.

• Post laminectomy with kyphotic deformity
• Translational instability
• Ankylosing spondylitis, rheumatoid arthritis
• Ossification of the posterior longitudinal ligament or diffuse hyperostosis
• Insulin-requiring diabetes mellitus
• Infection
• Pregnancy
• Metabolic bone diseases (e.g., osteoporosis, avascular necrosis, Paget’s disease, osteochondritis dissecans)
• Cervical disc replacement at more than one level

******
As usual, I have the document, if.......

Phil