BCBS reimbursement for ADRs at Stenum

[mnschott]

Hello All,

My name is Mike and 51 years old. I Live in Northern CO.
I was diagnosed with DDD (lower 3 Lumbar Discs) in 1998 and I have been managing pain using inversion table, diet and exercise (intermittent numbness in both legs below knees) until recently. I’m also self-diagnosed with “BHD, block head disease”, where when I was young/teens and used to pick up engine blocks, put 3 bundles of shingles on shoulder while climbing up a ladder, throw around 100 lb bales of hay, play every sport known to man, etc., I was certain that I was invincible and would live forever, injury and death is for the weak. => What an idiot, live and learn!
Last year an ADR surgeon in Loveland CO, Dr. Ken Pettine wanted to put me in an all expense paid FDA study to replace S1-L5 using Freedom Lumbar Disc but I only had a 50-50 chance of receiving it versus a first gen control disc, Pro Disc L. I’m an engineer and personally the mechanics, materials of construction of the new gen discs (M6 and Freedom Lumbar) greatly appeal to me. So at the time I declined and decided if and when I needed ADRs, I would have only the new gen ADRs implanted, regardless of cost.
2 weeks ago I had a serious hernia of L4-L5 disc, where right leg went completely numb and felt like my hip was going to explode/Sciatica, right foot drop, plus partial loss of bladder and bowl functions.
This past Monday I had a microdiscectomy that went well but still have numbness below knee in right leg and intermittent numbness in left leg below knee. Obviously need to heal and surrounding Lumbar discs are still a problem, but no guarantee that will not have some remaining nerve damage.
I have now scheduled ADR replacement at Stenum Spine on April 1st (hopefully this does not make me a fool!) for S1-L5 and L4-L5 and possibly L4-L3, which will cost me at least $41K US.
I have BCBS of Massachusetts and they claim they will not approve ADR surgery. So has anyone had success with them after appeal as a “medical necessity” for reimbursement?
Note,I have multiple US Orthopedic doctors who will willingly attest to the necessity.
And for those of you still fighting for quality of life, health, recovery and re-imbursement, I obviously wish you the Best.
Thank you in advance for your time and wisdom in these matters – Cheers, Mike

[Justin]

Hi Mike,

Welcome to the Spine Patient Society.

The size of your font is small--it might be hard for others to read. Anyway, I liked your self diagnosis of "blockhead disease."

2 weeks ago I had a serious hernia of L4-L5 disc, where right leg went completely numb and felt like my hip was going to explode/Sciatica, right foot drop, plus partial loss of bladder and bowl functions.

This past Monday I had a microdiscectomy that went well but still have numbness below knee in right leg and intermittent numbness in left leg below knee. Obviously need to heal and surrounding Lumbar discs are still a problem, but no guarantee that will not have some remaining nerve damage.

Did you have surgery in light of the partial loss of bladder / bowel function? EDIT: nevermind, I just saw your signature...I'm glad that the surgery was successful.

I have now scheduled ADR replacement at Stenum Spine on April 1st (hopefully this does not make me a fool!) for S1-L5 and L4-L5 and possibly L4-L3, which will cost me at least $41K US. I have BCBS of Massachusetts and they claim they will not approve ADR surgery. So has anyone had success with them after appeal as a “medical necessity” for reimbursement?

We've had quite a Spine Patients here at SPS that were reimbursed by Blue Cross Blue Shield for surgery at Stenum. Do a search for the following SPS Members: Ben, Terry, Bob (trkdoc714). Those are a few that come to mind.

Note,I have multiple US Orthopedic doctors who will willingly attest to the necessity.

Medical necessity letters will definitely help. Good luck! I wish you the very best.

[mnschott]

Hello Justin,

Thank you for info and best wishes.

My wife and I arrive at Stenum late Tuesday and Surgery Friday, April 1st.

Will let all know about results/experience.

Cheers,
Mike

[rhatzy]

Mike,

Depending on the type of health insurance you have, Stenum is a preferred provider for BCBS. I went to Stenum in January of '08. I am fully recovered and Stenum is a great place.

Wishing you all the best,

Mark

[mnschott]

Hello Mark,

Thank you for info, best wishes and your positive feedback on Stenum. It helps ease the mind and lower blood pressure.

Glad to hear your procedures have worked out well. Did you have the M6 ADRs implanted in 2008? And were you covered/re-imbursed by an Insurer?

Cheers,
Mike

[trkdoc714]

I'm actually waiting for the final check from Aetna for my surgery. My HR department had to get involved and they even denied the claim once before I sent the appeal back in it's entirety with the additional information they requested.

The timing in itself is ironic. I received an email yesterday confirming "the check is in the mail" from Aetna. Today is the second anniversary of the very successful ADR surgery I had at Stenum.

Insurance companies take advantage of any technicality they can to deny claims. An important lesson I learned was to compile and include every doctor's visit, surgical notes, PT notes, MRI, XRay, CT scan, radiologist report, prescription (you get the point) and submit a copy with each appeal.

When I was initially denied (excuse was "no previous conservative treatment" was attempted), I pointed out to Aetna that they had paid for all previous claims pertaining to my lumbar spine. I also failed to document the entire history with my initial HR appeal which necessitated a second appeal with them.

Good luck with BCBS. I now have them as insurance carrier. I've been told some of their plans are extremely ADR friendly.

Bob

[mnschott]

Hello Mark,

Great information!

Thank you,
Mike