CareFirst BlueCross BlueSheild now considering Artificial Disc Replacement as medically necessary

[mccauleyjw]

I have hired an attorney to get CareFirst BlueCross BlueShield to pre-certify a 2-level Cervical Artificial Disc Replacement using the ProDisc-C.

Although I do not know of any Artificial Discs that have been FDA approved for more than one level, it appears that CareFirst has recently changed its policy regarding one level. See page 5 on the below link.

https://provider.carefirst.com/wcmwp...c6bf8f0001c2ed

So, it appears that CareFirst has changed a one level cervical ADR from "experimental" to "medically necessary". This can be good news for those seeking one level ADR and one step closer for those seeking more than one level.

[New-disc]

Good news!!

.

[mccauleyjw]

Here is the latest Medical Policy Update from CareFirst BlueCross Blueshield considering a one level Cervical Artificial Disc as medically necessary when using FDA approved devices. Although I need a two level ADR, this is one step closer compared to three months ago in which CareFirst considered a single level as experimental.


Medical Policy - 7.01.100 - Cervical Vertebral Disc Replacement


My attorney and I will continue to push for coverage on a two-level ADR.

[laid up doc]

i don't know of any US insurance that covers 2 level ADR, cervical or lumbar. what many patients have done is pay the difference between a 1 and a 2 level - the 2nd device and a bit of extra OR time. the vast majority of the cost is covered by the insurance paying for 1 level...

good luck, but i wouldn't hold your breath. even if there are supporting studies that come out, insurances are not likely to jump onboard quickly - as you've learned.

[mccauleyjw]

Based on my research, consulting with my medical provider, and my attorney, there is no FDA approved cervical ADR that has been approved for more than one level as of this time. However, U.S doctors may do multi-level if they deem medically necessary

Understanding this fact, I understand that this is an uphill battle.

As I look around at various posts, I noticed that some people can afford to go overseas and some cannot. I noticed that some people have some time to fight the insurance companies and some do not. I noticed that some people just end up taking what the insurance company gives them. Personally, I cannot afford to go overseas and my time is running out. After all, what is the purpose of having health insurance? This is my health, not “Lets Make a Deal”. I look at the FDA and Insurance companies as just a bunch of bullies. To stop a bully,one needs to stand up to the bully.

In doing my research, I have found that people have stood up to the bully and won these battles. If you look around, you will find people that have fought insurance companies and got them to cover multi-level ADR even though the insurance company considered a one level as "experimental". That fact that CareFirst now considers ADR as "medically necessary" is a big step for those seeking this procedure.

Let me make one thing clear. This is a great forum to learn and exchange information. I cannot explain how beneficial this has been in my case. However, as you post and read, you will get a see a lot of posts/replys that may take the wind out of you. Keep in mind that the information is based THIER EXPERIENCES, not yours, and every case is different. Read, learn, find the right people, and stay positive.

I do know one thing. Insurance companies do not like being tied up in court!!

With this in mind, I hired an attorney when my original pre-certification was denied back in September 2011. I did not just hire any attorney. I hired an attorney that specializes in medical insurance and has experience dealing with CareFirst.

Anyway, after some research by my attorney and some calls to CareFirst, he told me two weeks ago to have the doctor’s office re-submit the original paperwork for pre-certification. Again, this was not an appeal. My attorney just told me to resubmit the original paperwork after he did his research and made some calls.

Well, to my surprise, the doctor’s office called me today and informed me that CareFirst BlueCross BlueShield has pre-certified a two-level Artificial Disc Replacement using the ProDisc-C. My surgery date is set for March 12^th

[trkdoc714]

Here is a link to the clinical trial for adjacent level Prestige discs. The results have yet to be reported/ published. The lead investigator was my follow up surgeon for my 2009 ADR surgery.

Study of the Safety and Effectiveness of the Artificial Cervical Disc - Low Profile Device at Two Adjacent Levels - Full Text View - ClinicalTrials.gov

I hope this helps,

Bob