Hi everyone - New Member fighting Mercy insurance

**sandysullivan32** · 06-10-2010, 08:47 PM

Degenerative disc C5-C6. Been through every treatment available in last 19 months. 44, excellent shape, workout out 6 days a week, extensive travel with work.

Started with Chiropractor, acupuncturist, Traction (suggested by surgeon), Celebrex, Physical Therapy, 3 Epidural Steroid Injections. Finally had enough and doctor said I am a perfect patient for Cervical Disc Replacement.

Mercy Insurance just denied first round because "it is investigational" I am meeting with insurance group tomorrow to find out more specifics on why claim was denied. Grievance procedures seem very long term. Pain getting worse everyday. Don't want to wait months - or go through all of this just to have it denied.

Any advice???????

**KBear** · 06-11-2010, 11:05 AM

I would highly recommend looking into clinical trials. This is what I did after being denied twice by insurance and not having it in me to keep fighting. I live in Dallas, TX and flew to Miami, FL for my surgery. Most, if not all, of the devices being investigated in the US are already in use in Germany and other countries and people are paying to fly there and receive them. Also, the doctors who do the clinical trials, are usually top notch, as the company that makes the disc wants the best, so they get good results, thus getting their device approved and making lots of money. Check out Home - ClinicalTrials.gov put in cervical ADR, then find an active enrolling trial, find the locations/doctors (feel free to post the doctors you are considering on here and we can help you out if we know of them), then call the locations and see if you fit the criteria. If you find one that is not in your area, it will require you paying for flight for pre-op, flight for surgery and follow up. However, depending on the study, a lot of them pay for all of your surgery costs and follow up care, so just the travel is on you.
Kathy

**sandysullivan32** · 06-11-2010, 12:31 PM

Thanks I will check this out.

**scduggan** · 06-11-2010, 01:39 PM

Dear Sandy,
Welcome to SPS! You story is very close to mine except that my DDD is at L4/L5. My heart goes out to you for I know EXACTLY what you are feeling. I am about 9 months ahead of you in this journey. I remember being so shocked and angry that my insurance company can dictate what care I receive......instead of my surgeon. As you probably already know some insurance companies cover ADR. I believe the others will follow and it is only a matter of time. I could not wait another minute. Kathy (Kbear) and I both travelled for our surgeries to be in clinical trials. In the beginning I was resistant to this because of the fear of the unknown.....mainly the "trial" disc. Looking back I know I did the right thing. I live outside of Nashville and I flew to Dallas (Texas Back Institute) for my surgery. I go back and forth for my follow-up visits.

My advice is the same as Kathy's. The only other thing you can do is try to appeal the denial from Mercy. This works for some folks. It did not work for me. I have UnitedHealthcare and they have a bad reputation for coverage of ADR. I spent hours and hours on my appeal and enlisted the help of friends with healthcare and legal backgrounds. This really does work sometimes.

I wish you luck and wanted to make sure you know you are not alone. You will get there! Please keep us posted.
CD

**Cindylou** · 06-12-2010, 12:48 AM

Welcome Sandy. Great advice from Kathy and CD. A clinical trial could very much be the way to go, if you can find just the right one for yourself. You are starting out on a good foot with a great group of folks in the SPS community who are here to support you all the way. My best to you in your quest for answers and long term pain relief. Cindylou

**sandysullivan32** · 06-12-2010, 08:37 AM

I talked to Synthes Prodisc yesterday (1-800-895-7764). They have a team of people that help doctors go through the appeal process. The doctor has to call and they send out the releases to sign to both the doctor and the patient. Then they do all the work. I am meeting with my doctor on Tuesday, so I will talk to him about this then.

If this avenue doesn't work I will look into the trials.