Insurance Denied Two Level Artificial Disc Replacement Surgery

[tspag95]

Hello....
I have DDD affecting bottom two disc. Two years ago my L5/S1 ruptured/herniated so bad I basically couldn't even stand by myself. My right side from my butt down to my toes felt like it had been run over my a truck. I rushed into surgery for discetomy which ended up removing basically my entire disc. L4/L5 was left alone...only showing slight deteriation with a very slight bulge. I was relatively pain free for a year but for the last almost year I have been dealing with what I describe as a constant medium to at times major dull pain with some nerve "twinges" here and there down my leg mostly in the morning on that first step out of bed. I'm seeing a doctor with the Texas Back Institute now. Just had new MRI, Xrays and discogram (I call this one the Jack Bauer torture test) w/ctscan. S1/L5 is bone on bone. L4/L5 disc has a tear in it. L3/L4 is normal. I'm pursuing the artificial disc procedure but cannot get insurance to approve it. First tried two level artificial...then a "hybrid" procedure which is fusing the bottom level and putting the artificial disc above it. My research now is geared towards what I need to do to get my insurance company to approve this procedure. Any help would be appreciated. I have GEHA insurance and have the option to switch to Blue Cross without a pre-existing condition limitation.

Tommy

[Justin]

Hi Tommy,

Welcome to the Spine Patient Society. I'm sorry that you are now looking at another surgery. I have not heard of your insurance company. However, we have had members on the Forum that we reimbursed for surgery in Germany (BCBS). I understand that going overseas is unrealistic for many people. Multilevel procedures are difficult to get covered from the get-go. Many patients have pursued a hybrid procedure like you mentioned (fusion at L5-S1 and ADR at L4-L5).

I can't recall the last person to be successful in having BCBS cover their artificial disc replacement surgery stateside. A lot of the insurance companies have changed their tunes about ADR: initially it was experimental and now they are stating that there are no long term (10+ year) studies in the US.

I am headed to the Texas Back Institute tomorrow, Wednesday, and I will be inquring about the mulitlevel arm for the Freedom Disc vs. ProDisc. My Dad is looking to get into the Freedom trial per Dr. Guyer's recommendation. My Dad has multiple levels that will be confirmed tomorrow with discography--I like your Jack Bauer comment--Ive had one and they are no fun. My Dad's procedure looks like multiple levevla at the moment, so I will let you know what Dr. Guyer has in mind after our meeting tomorrow.

Once again welcome and I hope we can help.

Hello....
I have DDD affecting bottom two disc. Two years ago my L5/S1 ruptured/herniated so bad I basically couldn't even stand by myself. My right side from my butt down to my toes felt like it had been run over my a truck. I rushed into surgery for discetomy which ended up removing basically my entire disc. L4/L5 was left alone...only showing slight deteriation with a very slight bulge. I was relatively pain free for a year but for the last almost year I have been dealing with what I describe as a constant medium to at times major dull pain with some nerve "twinges" here and there down my leg mostly in the morning on that first step out of bed. I'm seeing a doctor with the Texas Back Institute now. Just had new MRI, Xrays and discogram (I call this one the Jack Bauer torture test) w/ctscan. S1/L5 is bone on bone. L4/L5 disc has a tear in it. L3/L4 is normal. I'm pursuing the artificial disc procedure but cannot get insurance to approve it. First tried two level artificial...then a "hybrid" procedure which is fusing the bottom level and putting the artificial disc above it. My research now is geared towards what I need to do to get my insurance company to approve this procedure. Any help would be appreciated. I have GEHA insurance and have the option to switch to Blue Cross without a pre-existing condition limitation.

Tommy

Posted via Mobile Device

[tspag95]

Tell Dr. Guyer I said hi. He also did my brother earlier this year. He did a 3 level ADR. My brother's insurance company is BCBS but it's one of those self-insured plans through the company he works for. His employer basically paid everything for him. It was a great deal. He's already plaing golf and tennins with no pain. I'm so happy for him...he has two little kids that he couldn't even pick up prior to this surgery. This insurance thing is driving me crazy. Dr Guyer's office thought they might be able to get my cost down to about 35k or so if the insurance company would approve the fusion and then we do the hybrid. I would hate that but I guess in the big picture it's not that much money to be out of pain.

Thanks for your reply...
Tommy Spagnoli

[Justin]

Hi Tommy,

That's great news about your Brother! Those type of insurance plans do very well with coverage. I will tell Dr. Guyer hi for you. I actually saw Dr. Guyer in 2003 before my two-level artificial disc replacement surgery. Do to FDA restrictions at the time, I was not eligible for the ProDisc study (plus I had a previous lumbar surgery that excluded me). I would have had Dr. Guyer operate on me in a heartbeat--I think is is by far one of the best spine surgeons in the country (TBI is packed with "all-star" surgeons).

Good luck and if you want to talk by phone at any point, I'm all ears.
-Justin
Posted via Mobile Device

[scduggan]

Welcome Tommy!

I am in the same boat with you on the insurance nightmare. I need a one level ADR at L4/L5. I have United Healthcare. It is driving me crazy, too! Thank you so much for the cost info from Dr. Guyer. I had no idea about the cost. I just assumed it was a lot more. I spent hours and hours on an appeal letter....I also got a LOT of help with it from people in the healthcare/insurance industry. My letter was SO GREAT! United sent me a denial so fast it pretty much proves no one even read my appeal. Pretty disrespectful. Good luck on your quest! I second Justin on the great outcome for your brother. That is so encouraging.
CD

[tspag95]

Would you mind letting me read your appeal letter? I wouldn't know where to start. My email address is tspagnoli (at) gmail (dot) com if so. If not, I would understand. That 35k I quoted came from the guy who works in the certification department at Guyer's office...so I'm not sure how accurate it is. Although I do remember Dr Guyer talking to me about that option at my first visit and that number sounds familiar.

I just got denied the hybrid surgery. We are now trying to decide to work on an appeal letter or switch insurance companies to try someone else. I work for the federal government so we can switch at the end of the year and not be limited by pre-existing conditions. I have GEHA and my only other choices are Blue Cross, Mail Handlers, SAMBA, and then some HMOs and some CDHP plans...not sure what CDHP plans are???

We figured if we decided to appeal with GEHA then I would be stuck with them through next year while we wait for a response. Each procedure submission took six weeks to hear back from them so who knows how long it would take for an appeal response....unless maybe it's like yours and they just automatically deny it quickly...hmmmm. Then I could still switch insurance companies...probably worth a shot. I've got til Dec 14th to decide on my insurance.

This is all so frustrating. I'm basically living on muscle relaxers. I've tried everything else from physically therapy to chiro to acupuncture (very desperate on that one)...

[tspag95]

Hi there CD...Thanks for the letter....WOW, it did look great. I can't imagine how frustrated you were to open up that denial letter...so sorry! Dr. Guyer's office is assuring me that my current insurance company will not approve my procedure. I do have the option of swithing to Aetna at the beggining of the year without a pre-existing condition exclusion. Dr Guyer's office says they typically have pretty good luck with this company. The insurance isn't nearly as good as what I had but if they approve the procedure...that's really all that matters now.

Goodluck on your insurance battle! Again, thanks for sharing your letter.

[KBear]

Good Luck Tommy getting approval. I think I would switch to the company that Dr. Guyer thinks will approve the surgery. You could always switch back the following year to a plany you like better. Just curious, do you live in Texas, or come to see Dr. Guyer from somewhere else? I saw Dr. Zigler pre-surgery, ended up having surgery in Florida in a clinical trial and see Dr. Blumenthal for my follow up. I live in North Texas, about 20 minutes north of Dallas. Good Luck, Kathy

[tspag95]

Hey Kathy,
Thanks…I am filling out the paperwork for Aetna today…will submit for the surgery on the first day in January. I just moved down to Houston about 5 years ago. I grew up in the Keller, just south of you up there. Dr. Guyer actually did surgery on my mom’s back almost 30 years ago…then my brother this year. My parents are still there so I can recover at their house for a few weeks after the surgery. So how are you doing post surgery? It’s weird, no matter how bad I want this surgery, I’m still nervous as heck about it. My brother says that as soon as I’m approved for the surgery that I’ll second guess having it….I’m sure he’s probably right. My pain is constant every day now though so I’m pretty sure I’ll go through with it. How was your recovery period?

Take Care
Tommy

[KBear]

Tommy, I am real close to Keller, about 25 minutes. I used to do chiropractic there 2 or 3 times a week. I love going to Taco Casa there, where I grew up, In Gainesville, there was a Taco Casa and I loved it. It's probably a good thing that I don't live close to one, I would gain 20 lbs! Maybe next time you are in town, we could meet. I was able to meet DaveInAustin, last time I was at my sisters house in Round Rock. It's nice getting to talk to someone who is in the same position as you and gets it. You are lucky (if you can use that word when referring to back problems) to have a brother and mom who have been through this and can help you and support you.

Your brother is right, you will second guess your decision all the way to the operating room. Your mind will play tricks on you, you will feel better and think "do I really need this?" "Am I really hurting that bad? Or is it just in my head?" And on and on. You just have to weigh your options, research, research and more research and make the best choice for you, with the information you have. I wanted to go in and have no regrets, regardless of my outcome, good or bad. I wanted to know that I did the best I could with the information I had.

I am glad that I had the surgery. I am not 100% pain free; but I knew that that was a possibility. I have about a 60-70% pain reduction, so much more manageable. Plus, I had reduced my meds early on, which then in turn made my doctor want to keep me on a lower dose. Which made me be in a lot of pain, so I couldn't do anything other than lay on a heating pad. I think this delayed my recovery, as a body in pain does not heal as well as one not in pain and I wasn't doing any core stregnthing or exercises. I am now on a new medication, which is controlling my pain really well, so I am active again. I still think that I will get more pain reduction and possibly reach 100% pain reduction. I have heard many people say that it took a full 2 years to reach their optimum recovery, so I am still hopeful. Even if I don't get there, I would still do the surgery again, as I think it was the best shot I had at getting better. I can live with a 3 or 4 pain level, versus the 9 or 10 I had before.

Good Luck and Keep in touch, I will be thinking and praying for you!
Kathy