New - Appealing TriCare for cervical arthroplasty and seeking assistance

[wardbro2]

It great to find this forum and all of the information.

Request #1:

1. DOES ANYONE HAVE ANY INFORMATION ABOUT WHICH MILITARY HOSPITALS PERFORM CERVICAL ARTHROPLASTY AND HOW OFTEN?
TriCare denied my surgeon's request for the procedure verbally on Dec 29, 2011, and formally (in writing) on Jan 12, 2012.
They stated that this procedure is not a covered benefit as it is considered experimental. However, I am told by my surgeon (with colleagues at Walter Reed Military Medical Center) as well as by Medtronics that this procedure is being performed on active-duty military members. My primary point in my appeal to TriCare is: You cannot consider a procedure as experimental and unavailable to one sector of your patient population if you allow this procedure for a different sector of your patient population. Knowing which Military Medical Facilities perform cervical arthroplasty and some rough estimate of frequency that these medical facilities perform this procedure would be a great help in my appeal.

Request #2:

I am 52, very active and diagnosed with DDD and some arthitis. My past 8 days have been nice. I'm off the mountain of pain meds that had me in a fog bank for 50 days. Atophy in my right deltoid and forearm might be getting better.... not so sure. I want to think that with my pain subsiding, I may not need any surgery. My doctor says that this condition (DDD) is not going away, and I will likely be back to the place of bad pain again (who knows when). He recommends surgery soon, primarily due to the significant loss of muscle on my right side. ANY THOUGHTS OR COMMENTS FROM THE EXPERIENCED MEMBERS SUPPORTING THE NEED TO CONTINUE WITH PLANS FOR SURGERY OR HOLD OFF IF I AM ABLE TO MANAGE WITHOUT MUCH PAIN OR PAIN MEDS (OR NEW CONSIDERATIONS)?

My Background:
I'm an airline pilot, but also AF Reserve officer for over 28 years. I am on TriCare (Reserve Select).
I've come a long way from the horrible pain which started to retreat around Jan 20, 2012. Some pain and numbness still exists, but tolerable. My big concern is the atrophy in my rt deltoid and forearm. I am doing PT twice weekly and slowing returning to mild expercise, but can't see much improvement in my muscle mass yet. I really enjoy training and competing in triathlons. This past year I had fun with the short sprint events and did well enough in Nationals to make Team USA for the World Championships this Oct 2012 in New Zealand. I am certain that ADR is the way to go for me, and am worried that my risks for long-term damage may limit the time I have to fight. Thanks for your consideration.

[mccauleyjw]

My first Neurosurgeon in the DC area recommended Fusion or Cervical Artificial Disc Replacement using the Prestige Artificial Disc. The Prestige was one of the first Artificial discs to be FDA approved and is widely used by the Military for active members because of the quick recovery time compared to fusion. In other words, it is a convenient way for the military to put active duty members back in the field instead putting them on the disabled list. Understand that what is convenient for the military, may not be best for the individual.

Although I do not know of any Military Hospitals that perfrom the procedure, your logic in your appeal is sound. However, I highly suggest the you do your research here and there regarding Artificial Discs, for the Prestige Disc is consided by many as outdated technology. Again, we are talking about the same military that does not give our soldiers proper armor to protect themselves.

As far as how long one can hold off before permanent nerve damage will occur, you need to discuss that with a good neurosurgen. I have been dealing with pain since 1992. Over the last few years, there has been little pain. However, in the summer of 2009, I noticed extreme weakness and atophy in my left arm. After seeing several specialists, I finally found Dr.Paul McAfee in Towson MD in August 2011. Dr. McAfee recommended that I have a two-level ADR c5/c6 and c6/c7 using the ProDisc-C. He explained that he is pretty sure that my arm will return to 100% after the procedure. He explained that I did have some time to fight with my insurance company. However, if I noticed weakness in my legs, we need to move quickly for permanent nerve damage will occur.


Seek and you will find. This is a great place to start. Good Luck

[wardbro2]

Thanks for the information Mccauleyjw. Very much appreciated. I have been working so much on the appeal that I haven't given time to comparing the Prestige to other devices. My Neurosurgeon at Rush University Hosp (Chicago) has some patent interests in the device and participated in the trials... which is why the Prestige is his preferred device. I will broaden my education on devices. Any areas / links you found helpful? THANKS!

[mccauleyjw]

Yes, this all can be very overwhelming and frustrating. My first neurosurgeon is considered one of the best in the area. Yet, he was hard to get a hold of an his office staff refused to help me with insurance. I later found out that he was one of the best when it came to fusion, but had only done a handful of ADRs using the Prestige.

Frustrated, I kept searching the web looking for answers, devices and doctors. I then stumbled here on Spine Patients Society (SPS). Congrats to you for joining. This is the best place to start.

Before you battle the insurance company, you should look for a Doctor that is Pro Artificial Disc Replacement (ADR). You need to find out who is in your area and get a second or third opinion. ADR is not for everyone. So, it is very important to find a good surgeon that is up to date on the latest technology. Learn how to navigate and search on SPS and post questions if you do not find. In one of my posts, I asked if anyone knew of a good neurosurgeon in the Washington DC area, that is Pro ADR and accepts BlueCross BlueShield.

If you click on my username, you will see an option to view all my posts. This should give you a good idea how this site works.

Here is a good place to start to find a doctor in the US:

Domestic Travel for Spine Treatment


As far as what is the best device, that can be very complicated. The Prestige was one of the first ones to be FDA approved. Since then, several others have been released with better technology. It is my opinion that the M6-C is one of the best. However, it is not FDA approved and a company contact was not sure when they will funds to continue FDA testing. However, you will read that has not stopped people from going overseas to get the M6-C with good results.

As much as like the design of the M6-C, I have concerns. What happens if I return back to the US and complications occur? Where would I find a doctor for a non-FDA approved device? Plus, I am sure that my insurance company will not touch it, because it is a non-FDA approved device.

Here is a good place regarding Artificial Discs:


Artificial Disc Replacement



I can honestly tell you this is one of the hardest choices I have ever made.


Option 1 : Get a two-level fusion which is normally approved by most insurance companies. Sorry, I have waited almost 20 years in pain for the new tectnology. So, this is not a option.

Option 2 : Pay out of my pocket and go to England and get two M6-C or two ProDisc-C. The cost would be around $45000 compared to $90000 in the US. As much as I like the M6-C, I just do not have $45000, plus the concerns I mentioned above.

Option 3 : Decide what is the best FDA approved device and try to get pre-certified. In this case, I decided on the Pro-Disc-C and my current neurosurgeon avocates this. However, I knew this will be a fight. So, I also retained a good heath insurance attorney. This is the path I took and we were able to get CareFirst to pre-approved a two level ADR using the ProDisc-C.

This whole process took over a year.

That being said, it is important that you do your homework. There is no use fighting an insurance company until you decide what is best for you. In other words, how do you fight an insurance company if you do not know what you are fighting for?

Again, there is a wealth of information here. Do not just wait for replies. You need to keep searching this site. Go to "Google" and enter best cervical artificial disc.

I know that this is a big decision and it is hard not to panic. However, give it some time and you will have a game plan.


Cheers