New Member / Three Level Lumbar ADR

[Alan Hardy]

Hello-

I would like to introduce myself as a new member of the Spine Patient Society.
I have been avoiding multi-level lumbar fusion (recommended by three surgeons locally) for nearly seven years.

In December of 2010, after exhausting local medical resources, I traveled out of state for additional diagnosis from a well known spinal specialist. This diagnosis included a discogram, a procedure incidentally that was not offered by any of the three surgeons recommending spinal fusion.

The diagnosis indicates I require a multi-level L3/L4, L4/L5 and L5/S1 ADR.
This diagnosis was confirmed by a second spinal specialist in Germany.

I have aggregated a comprehensive presentation quality document including; two letters of medical necessity, all recent films (MRI, X-Ray, Discography), efficacy, cost comparisons U.S. vs. Germany, etc.

My request for a surgical pre-authorization for a multi-level ADR procedure from BCBS (including Blue Card coverage) was recently denied.

I look forward to helping others achieve accurate diagnosis in a reasonable timeframe (preferably less than 7 years) resulting in meaningful options. I will be looking for any assistance forum members may be able to share regarding insurance appeal and or approval.

[KBear]

Welcome to the forum. I'm not any help on the insurance appeal, as mine was unsuccessful. Have you considered having a hybrid?

[Alan Hardy]

Hello and thank you for welcoming me to the forum.
I appreciate your recommendation to consider hybrid procedures.

As I'm sure you can imagine, I have discussed numerous options with spinal specialist in both the U.S. and Germany. Their conclusion, a multi-level ADR is the best option for; mobility, pain reduction / elimination, normal active lifestyle and long term results.

I believe this course of action is more difficult to have approved by insurance carriers.
Unfortunately personal goal is to end up with the best solution for a long active life.

Thanks again

Alan

[Katie]

I'd like to welcome you as well. I had to travel out of country also, but to Brazil and am one year out from a very successful surgery. My appeal has been a wash as well, so I can only offer suggestions, and hope that the insurance comes into the 21st century soon.

[Justin]

Hi Alan,

Welcome to the Spine Patient Society.

Unfortunately, your story of having your surgery denied is not a unique one here at the Spine Patient Society. Three level lumbar artificial disc replacement (ADR) surgeries done in the United States are pretty rare (both in terms of insurance coverage and the surgery itself). There have been Spine Patients in the past that did have 3-level lumbar ADRs in the United States, but these patients were "compassionate cases."

As you have noticed from your research, a 3-level ADR is commonly performed in Germany and other countries. I think if you are dead-set on ADR, options outside of the US are your best bet.

Also, in regard to the insurance coverage--there have been a lot of SPS Members recently denied for ADR. If you search the Forum, you should pull up a lot of pertinent threads. A SPS Member, "Researcher," was denied for ADR surgery and he put together an appeal(s) with hundreds of man hours & supporting documentation to no avail. He ended up traveling overseas to have his operation performed.

These insurance companies uphold their denials based on recommendations from physicians & surgeons they claim are experts in the field of spine surgery. However, I have found that many of these so-called "experts" are actually in every specialty but orthopedics / neurosurgery. It's truly a flawed system. The insurance companies will continue to deny and their tune as to why they are denying care will continue to change like the wind.

Good luck and keep us posted!

[trkdoc714]

Welcome Alan. I had to pre fund my surgery as well (thanks Mom). Although I was told last month the HR department had finally agreed to pay the balance of the claim (rest of your money's coming, Mom). I guess their instruction letter to Aetna ordering them to pay the claim has been denied so they're appealing..........

Justin hit perfectly regarding the system being flawed. My first encounter with the Aetna consulting MD was amazing. She had no idea what ADR meant let alone where it went. My guess is she was a dental student working her way through college as a consultant. She was overwhelmed with the research I sent in with my appeal(s).

If there is anything we can do to help, just ask.

Bob

[Gilbert P]

HI Alan

Welcome. I walk in your shoes, Three or four levels need help, Workers Comp case will not cover and insurance well you know the rest.

Now seeking ways to pay out of pocket to regain some life.

We are here to support and help

Gil

[Alan Hardy]

Thank you for your thoughts and considered response.
It is always something of a relief to hear from others who have shared this experience.

I have recently scheduled a three-level ADR with Dr. Bertagnoli / Pro-Spine in Bogen Germany.
My debilitation and pain have reached a point where I can no longer wait for the insurance company to respond favorably. I will however, continue to aggressively appeal my case with the insurance company.

It is ironic that a multi-level ADR procedure in Germany will cost less than a three level fusion in the U.S. Sadly the long term costs to insurance companies for a multi-level fusion would be astronomical.

Best wishes

Alan

[melly]

I am also a new member and at the early stages of considering ADR at possibly 3 levels.

My insurance company in New Zealand have stated that they would fund the operation in New Zealand (but they only seem to do 1 level here and are not too experienced) but not in Germany.

If you have any advise or would be willing to share your research to assist with my appeal to insurance company I would really appreciate it.

Thanks

[Alan Hardy]

Hello-

As I am in the middle of my own appeal, I am unable offer any significant advice.
The U.S. is an unfortunately litigious place. One woman, Laurie Todd, has had great successes in the US with her insurance appeals. She offers a book and DVD on-line as an aid to formatting your appeal. The cost is low and there are some very helpful strategies.
Though I am not sure how much of this is applicable in New Zealand.

My (three level) ADR surgery was completed 6 weeks ago. I am pain free for the first time in nearly eight years. The surgeon, post-surgical care and all of my results have significantly exceeded my expectations.

Here in the U.S. the FDA has only approved single level procedures, though oddly multi-level procedures are routinely performed here. The most experienced multi-level ADR surgeons in the US have a fraction of the experience of the surgeon I elected to use. Accurate placement of the devices is absolutely critical for a successful outcome. Ensure you choose a surgeon that uses a fluoroscope throughout the surgery to accurately place the ADR devices.

Do your research carefully. A highly marketed surgery center in Northern Germany may have done a lot of good work, but they have also done a lot of very poor work. I have interacted directly with individuals (plural) that have had exceptionally poor outcomes requiring revision surgeries.

All of the other patients at the time of my procedure have experienced similar poor / dismissive service and bureaucratic corporate responses from their insurance companies. Ironically, most of the insurance companies had approved fusions for these patients. As you are well aware, fusions result in higher cost, short, middle and long term, but they are approved here in the U.S.
All but one of the aforementioned patients are appealing. One will be taking legal action on a massive scale against the insurance companies.

I would not consider letting a surgeon near my spine that has not only performed a significant number of these procedures. Additionally, my criteria included a surgeon who has also pioneered and advanced the art and science of spinal surgery.

Three of the patients during my hospital stay had poor prior surgeries that required significant revisions. In many cases the results of a revision surgery are an improvement over the poorly performed surgery. Regardless the results can be less than ideal.

I am delighted I persevered and rejected the diagnosis of multiple US surgeons prescribing multi-level fusion as my only option.

Great results are possible.

Good luck!