[Artificial Disc Replacement / Lumbar] Lumbar Disc Replacement (Charite L4/L5)

[bman]

Hello gang

My lovely spouse sought out assistance in finding out how to get BCBS to pay for a ADR hear in the Heart of Texas, and came across this sight.

I have been a PT for nearly 2 decades, and as I spent the majority of my (mis)spent youth burning the candle in every way possible, I have more pain issues than you can shake a stick at. However, with regard to my spine I purposely did NOT seek out diagnostic data for two decades to protect my reputation.
I say this because Physical Therapist's have the highest disability index, and up until now fusion could easily put one out of business - as its a physical job-duh

By this year though, I bit the bullet. What I thought was purely SI pain /dysfunction in origin progressed to be a 12 mm centralized disc protrusion at L4/L5. The only reason I am not in a [wheel] chair now is that I have been blessed with an "abnormally large central [spinal] canal!

So, I subjected myself to all the rigamorole that BCBS could muster - MRI, CAT, Discogram -replete with wide collar shirts and platform shoes. jordache' jeans, BeeGees music and now I have been "pre-authed" for Chartise Lumbar ADR Oct 28th.

The problem now is that even when a carrier "pre-auths" this surgery, they can (and in my case most likely will) deny payment AFTER the surgery is complete. So that is why I am here, to gain knowledge for the post-surgical lawsuit.

So, if I can reciprocate the assistance I will receive from you all during all of this, I would be happy to provide any information -as appropriate - to help all of you.

Thanks and Hello again
Bert (BMAN)

[KBear]

Bert- Welcome to the site! I have actually never heard of an insurance carrier pre-authorizing ADR and then not paying for it. I have heard of them denying ADR on a pre-authorization and then paying for it after the fact. It also depends on if your BCBS is through an employer, through a self employed policy, etc. They vary greatly within the same insurance carrier. There are some BCBS people on here who had ADR payed for no problem and get awesome coverage. Then there are people like me who have individual policies and can't even get them to pay for my anti-depressant.

[trkdoc714]

Bert,

Sorry that you're finding yourself here but I'm glad you found us.

Did you mean Charite ADR? If so, that might be the "demon in the detail" for the insurance claim. Charite was the first ADR approved by the FDA for use in the US. I believe DuPuy has removed the disc from the market. I did a quick search of their spine product site and came up with no matches for Charite, so it might be true.

If BCBS approved a discontinued disc, that might be their angle to deny ADR surgery for any other disc (ProDisc is currently FDA approved in the US). I hope that's not the case since insurance companies are our friends and allies.......

There are several others that have had or are going through the process of getting ADR approved through their insurance companies. I hope there is a member that has had success with BCBS of Texas that can share their secrets with you.

Good luck to you. I hope your disc problem can be resolved without surgery!

Bob

[bman]

Thanks to all,

My surgeon just finished an extensive "re-working" of this ADR model in Plano at the Texas Back Institute, and has successfully done this as well as Bryan(?) ADRs here as recently as this month. I looked into the Pro-disc and sought out a 2nd with a very talented surgeon who works that system.

My concern with the PD is lack of any discernable rotational compense, which although minimal in the truest sense in the lumbar spine is necessary in part with regard to sidebending / lateral flexion. I want ALL of that 8 degrees if motion, in as many planes as possible

You (or in this case ME) are taking a chance getting any ADR, especially in this age of what the Bible labels as Plagues and Pestilence. Infections scare the you-know-what out of me, probably because when you've worked in a hospital you can access infection rates....

The long - term issue is the issue..... Depuy has had its problems now with breakdown, and its the plastic that seems to break down over time. I think that was the issue with their ADR, and I HOPE its been resolved.

However, on that same note, crafty surgeons have now successfully completed ALIFs (modified) to fixate failed ADRs, thereby maintaining anterior-lateral approaches, and thereby further reducing scar complications.

Im nearly 50, and as of now I can't stand statically in one place for 20 minutes without paying for that for DAYS, so Ive weighed out the good with the bad. I know first hand visa-vi 100s of patients the problems that can and DO occur with traditional fusions, with regard to short AS WELL AS long term outcomes.

ALIF life-spans are at best now 10 years, and you are still left with that pesky FUSION, so I am taking a SEMI-calculated risk.... but isn't life full of those


Regarding getting pre-auth followed by denial of payment, that is how I got turned onto this forum (again, by my lovely wife - Brownie Points anticipated) was that a member here has recd the same sx in Texas through BCBS, which to date has - at least in Houston - not been accepted... Insurance companies the country wide add that clause to every MD contract- that being the right to decide after the fact that they won't pay....

It's the future though-ADR that is - and as long as people occupy this planet people will have back problems, and back surgery.
I blame gravity and very good cheeseburgers for that, btw!!!!

Bert L. PT

[ajj1001]

However, on that same note, crafty surgeons have now successfully completed ALIFs (modified) to fixate failed ADRs, thereby maintaining anterior-lateral approaches, and thereby further reducing scar complications.

Hi, do you have any information/studies on the ALIF revisions or know people it has been successfully performed on? I've not come across any fusions over ADR done from an anterior approach but I'm not in the medical field so will probably have just missed them!

thanks
alison

[bman]

Here you go Alison, at least one example: http://phx.corporate-ir.net/External...R5cGU9Mw==&t=1

Hope this helps.
B

[claudia]

ALIF life-spans are at best now 10 years, and you are still left with that pesky FUSION, so I am taking a SEMI-calculated risk.... but isn't life full of those

Hi, I was wondering what you meant by a life span of 10 years? are you referring to the adjacent level damage?

Thanks!

[Cindylou]

Yes, I was just wondering the same thing. I have never heard this said before. Are you referring to the adjacent discs?

[KBear]

Also, to have a revision is a huge deal. Granted there have been successful revisions, but more often than not, the patients would have been better off having the fusion first. Fusion success rates drop dramatically when done as a revision. I went into the ADR thinking, well if this doesn't work out, then I'll just have revision. I didn't realize the seriousness of it at the time and I'm very lucky that my surgery worked and I don't need a revision. Here are some links to a couple of stories of revision patients:

L4-L5 Prodisc ADR removed and revised to XLIF and PLIF

"A Grave Error" with Prodisc Implantation in Germany

Some of the patients that need revisions should have never have had ADR in the first place, while others have unforseen problems that cause the ADR to need to be removed.

[bman]

That is THE # 1 reason for ADF/TDR failure world wide- ad well as one of the two main arguments insurance carriers use with regard to denial of payment. In my example I am a perfect candidate for replacement.
Too many procedures are done on pts. with poor facet potency and excessive degeneration of one or more bodies. ADR isn't for everybody!!!!