[Artificial Disc Replacement / Cervical] Wife: C5/C6 and C6/C7 Fusion, C3/C4 Artificial Disc Replacement Surgery Denied by Insurance

[mschmidt]

I am looking for some information to help in appealing BCBS Anthem denial of ADRC surgery for my wife. They are denying it due to (Investigational and Not necessary). My wife has C5-6 and C6-7 fused and she has degenerative disc issues. She now needs to have the ADRC surgery for C3-4. If she has this fused she will become I feel and so does the doctor disabled. She is too young for that. I believe from all that has been read that if C3-4 is fused she will be looking for an aditional fusion of C4-5 in the near future. I believe that the ADR will pro-long any additional surgery for a longer period of time and better her quality of life. Now all we are able to do is manage pain with prescriptions and injections, neither one of these has helped and this has been on going for over 4 years. We felt we were going to get the proper surgery through United Healthcare appeal but then our insurance changed to BCBS Anthem of Kentucky. So we have started all over again. This has been a very bad experience with these folks. I have seen people in the hospital on medicaid receive much better care with the medicaid coverage. So now I am ready to go to the HR group of my company to argue this decision. I would like to be able to see the BCBS approval letter that is posted and the list of Insurance carriers approving the ADRC surgery. I understand what my wife is going through because I also have fusions ant C5-6 and C6-7. I had my first surgery back in Feb of 1986 and second for xmas in 2000. But I am in good shape and I need to take care of my wife. I have not done a very good job at that or she would have had the surgery already. So my goal is to gather additional information to facilitate my company in pressing BCBS Anthem of Kentucky to approve this surgery. Thanks for welcoming me Justin and I hope you and your army (society) can assist me with some helpful documentation. This is the first time on a site like this so bear with me if I make mistakes.

[trkdoc714]

I'm surprised BCBS denied your request. The FDA had approved ADR devices for both cervical and lumbar use.

Prepare a well researched appeal letter. Don't let them bully you or deny you. Don't lose your cool. Always ask "why" or "why not". Wear them out.

Laurie Todd wrote a good book on battling insurance companies (The Insurance Warrior). Here's a link to some of her ideas.

The Insurance Intelligencer -- Not enough scientific proof? (Treatment denied despite appeal)

Good luck. You came to the right place. We're here to help.

Bob

[Justin]

Thanks for welcoming me Justin and I hope you and your army (society) can assist me with some helpful documentation. This is the first time on a site like this so bear with me if I make mistakes.

Sure thing, mschmidt. The Spine Patient Society is here to support you and your wife.

Here is a link to an approval letter from BCBS regarding a Cervical Artificial Disc Replacement surgery: Cervical Artificial Disc Replacement Approval Letter (5/15/09): Blue Cross Blue Shield of TX. I would check in your BCBS benefits booklet to see if the wording is similar to the wording found in the BCBS benefits booklet in Texas--that might help with your appeal.

Good luck and please let me know if I can help. BTW... my hats off to you for helping your wife through all of this--you're a good man.

[KBear]

Welcome to the site and that is great you are fighting for your wife's care. I had no success getting my insurance to pay, so have no experience there. I know it varies from state to state, if it is through an employer or an individual plan (self employed people get these- what I have). I think it also varies from employer to employer, and I know several have went to HR and got more benefits from their health insurance. I also have noticed that many insurances deny up front, but when sent the bill will pay a good portion to all of it. There is a thread on this in the insurance forum, here is a link Was your surgery paid for by insurance? Or not?
Good Luck!
Kathy

[runagain]

Msschmidt,

PM me.

R

[Cindylou]

Welcome mschmidt, unfortunately, that is the typical answer most of us received in our denial letters. All of the above advice is so good, no need for me to embellish. I was just going to add as encouragement, my husband's company is self insured, and altho I was denied 3 times (I even did a formal, in person, presentation) at the end of the day they surprised us and paid half of it. So hang in there, cuz you just never know. Cindylou