Washington DC, Artificial Cervical Disc Replacement not covered by CareFirst BlueCross BlueShield, no assistance offered by doctor.

[laid up doc]

runagain -

i think that ADR will one day be the gold standard in select patients - and that neither fusion NOR should be denied outright. problem is, the data on the Charite and Prodisc trials isn't totally convincing, and they were NON-INFERIORITY trials. my understanding is that the Maverick data is much better, but since the study was funded (as far as i know) by Medtronic - hard to say they didn't pull some stats magic, and i haven't seen the full article to see their randomization, how many patients were lost to followup, what their pt population was like, etc etc.

part of the problem is that different insurance companies choose to take one stance or the other - they cover ADR OR fusion. imho this is absurd!!! some people with persistent, symptomatic disc problems are clearly better indicated for one or the other. some are contraindicated for one or the other... yet from what i have seen, it doesn't matter.

i'm going even more into debt to get what is best for me - and M6L ADR. i've invested easily 6x the cost of the surgery in my education and haven't really even begun to pay it off. i'll put up a fight against Aetna b/c every surgeon i saw told me that a prodisc is not the right treatment for me, for a variety of reasons.

[Lydia Watson O'Brien]

I hope this isn't to late. I don't know of any Dr's in VA but I had a two level disc replacement done in my lower back at the Stenum Orthopedic Hospital in Breman Germany. I am currently looking at going back to have two levels in my neck done. Hope it's a little helpful.

Lydia

Hi Everyone,

This was also posted in my introduction, but I wanted to post it under Health Insurance.
My name is John. I am 47 year old male living in Alexandria, Virginia

I am Self Employed and have CareFirst BlueCross Blueshield for my medical provider at $400/month.

I started Chiropractic treatment in 1990 for lack of natural curve in cervical spine and degeneration if disc. Treatments fairly effective in pain reduction. However, I was told at that time that surgery maybe needed in the future and it would be in my best interest to hold off as long as I can for newer technologies.

I saw Dr. Simon Fishman, in October 2010, for numbness in left arm and weak left tricep. An MRI was ordered along with EMG testing. MRI reported the following findings: Discogenic disease, resulting in central canal and bilateral neural foraminal narrowing at C5-C6 and central canal and left neural foraminal narrowing at C6-C7. Findings at C6-C7 may account for patient's left-sided radicular symptoms. EMG tests support MRI finding.

I Saw Dr. Charles J. Riedel, Neurosurgeon, Arlington Virginia in March 2011. Dr. Riedel recommended Anterior Cervical Discectomy and Fusion (ACDF) of the C-6 and C-7 or Cervical Artificial Disc Replacement. I have been informed that he has done many ACDFs, but only 10 to 20 Cervical Artificial Disc replacements using the Prestige Artificial Disc.

I would like to have an Cervical Artificial Disc Replacement. I do not want ACDF or any type of fusion. However, CareFirst BlueCross Blueshield states that Cervical Artificial Disc Replacement (procedure code 22856) is still considered experimental at not covered. Although I feel Dr. Riedel maybe a good surgeon, Dr. Riedel's staff is not willing to assist me in getting CareFirst BC/BS to approve a Cervical Artificial Disc Replacement, stating that ACDF fusion is my only choice.

I have waited nearly 20 years in pain for a newer technology and to avoid fusion. There is no doubt in my mind that Cervical Artificial Disc Replacement is much better that fusion. However, I cannot find a doctor that can help me get this procedure approved. I am worried that permanent nerve damage may occur if not treated soon.

Can anyone recommend a good surgeon in the Alexandria/Washington DC area that accepts CareFirst BlueCross Blueshield and is "Pro" Cervical Artificial Disc Replacement that will also assist in getting the procedure covered by my health insurance.

Thank You,

John

[mccauleyjw]

Hi Everyone,

Here is the latest. I was scheduled for surgery September 28, 2011, but never got pre-approved for a 2 level cervical ADR using the ProDisc-C. So, we cancelled the surgery.

On September 30, 2011, I received a letter from CareFirst BlueCross BlueShield denying the procedure calling it experimental. I find it interesting the pre-approval paperwork was submitted way in advance and the denial letter was dated around September 15, 2011. However, it was post marked September 28, 2011. It is like CareFirst was attempting to stick me with the bill had I had the procedure.

Although I am still frustrated, SPS has been a great resource helping me with my goals.


1- Find a doctor that is "Pro" Cervical Artificial Disc replacment. DONE/Dr. Paul McAfee

2- The Doctor submits paperwork stating that it is a medical necessity for pre-approval. DONE/DR. Paul McAfee's Office

3- Most likely CareFirst declines the procedure calling it experimental. DONE/CareFirst denied the procedure calling it experimental

4- My Attorney writes the appeal. In progress


Although Dr.Paul McAfee's office is willing to file an appeal. My Attorney has instructed that they do not submit an appeal for he will do it. One has to keep in mind that the doctors and insurance companies are in the same network/bed.

Bottom-line: I found a great doctor and things are in motion. I do have several things to my advantage as far as the appeal/legal process.

1: I am self insured, not part of a large group. This keeps it low-keyed

2: If we do go to court, it will be in my and my attorney's backyard.

3: The CareFirst network is inconsistent for other CareFirst insurance carriers across the nation have approved cervical ADR. I also find it interesting that CareFirst has posted the below article.

Cervical Disk Replacement Surgery


Although I should not have to, I will travel to the UK to have the procedure done if I lose my fight with CareFirst. However, I will continue to fight CareFirst for reimbursement.

Again, thanks for all the help!

John

[trkdoc714]

I'm not defending BCBS but it may be the 2 level ADR that they deem experimental. I know an FDA trial was done for a 2 level Prestige but don't know the results or if final approval was granted.

If you have international coverage, you stand a good chance of reimbursement for an overseas surgery. I know that Drs. Clavel and Ritter-Lang both have had several patients reimbursed by BCBS for cervical ADR. I can't recall any 2 level recipients have been covered domestically but there may be a precedence to use legally with the international approvals.

Good luck to you John. Fighting insurance companies is nearly as miserable as the pain from your bad discs.

Bob

[laid up doc]

from my understanding, trkdoc is right. it's not ADR per se, it's 2 level. i don't know of any US insurance that covers 2 level ADR in the US - the studies aren't out yet to support it.

you may want to start investigating your international coverage, and consult w/ whomever you see fit of Ritter-Lang, Boeree, Clavel... or i believe some have gotten their insurance to pay for the first level, then they foot the bill for the 2nd, in the US. i don't recall which carrier, one was Aetna.

fwiw, to update my prior post on this thread - i have decided that the pain of fighting Aetna is not worth it. i have what i needed - the ability to return to my job. i am fortunate that i can pay down my surgery bills (loan from family) on my own and just want to move on.