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Health insurance won't

itzamemomiitzamemom Posts: 39
edited 06/11/2012 - 7:34 AM in Health Insurance Issues
approve and ADR for me. My doctor tells me I need an artificial disc replacement at my C4-C5. My insurance co. will not approve an ADR but quickly approved a fusion. According to my doc, he could do the fusion, however, it would not be without problems for me in the future. He explained that my 2 disc levels below C4-C5 have issues as well and can become worse by having the fusion, thereby leaving me to look forward to future surgeries. I was under the impression that this procedure was not an experimental/investigational surgery and have found on the FDA's website the letter of approval for the ADR surgery. I'm frustrated, scared, angry and totally stressed over this. Does anyone have any ideas or words of wisdom that may help me get the insurance co. to approve me for the ADR....please.

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Comments

  • on this web site, appeal it. I believe some insurance companies do still consider it experimental. But I know there are a few on here that fought for ADR and got it. Unfortunately I don't remember their names.

    It should be strong evidence that a fusion will put pressure on those other levels... However, what would the game plan be for you if you did get the ADR, and your others did continue to collapse? I don't believe they can do many multiple level ADR's. I could be wrong though. I would definitely ask your doctor what your option is even if you did get the ADR and you other levels collapsed. Just something to consider. :)

    Take care and good luck! :)

    Caity
  • You might find this helpful.... :)


    http://www.spine-health.com/forum/neck-pain-cervical/disc-replacement


    Just copy and paste the link on a new browser.

    Caity
  • jlrfryejjlrfrye ohioPosts: 1,110
    You need to appeal with your insurance company. Have the doctor write a letter of medical necessity along with the probable outcome if the surgery is not done. Also make sure he includes the weakness of the other disc and that a fusion will more then likely result in future surgeries. Include with your appeal all test results along with all previous treatments pertaining to your cervical disc. Also request an expedited appeal due to the unnecessary pain the insurance company is putting you through. Stress that medications are not giving you the relief you need. You will more then likely be denied but do not stop , file a second level appeal (expedited) if you lose the second appeal you have the right to ask for a mediator
    that is not an employee of the insurance company for a final decision. Also you will want to start a journal for everytime you speak with insurance company. Keep dates, operator names and write down as much of the conversation as possible. Also ask for a reference number for each phone call. DOCUMENT everything. It can work to your advantage to have all this. Is your insurance bcbs? let me know if I can help you in any way. I fight the ins co, daily, I work for drs. So I am here if you need help
    Susan
    feel free to PM
  • Another thing that maybe useful is finding out what ADR your doc is going to use. Then contact the manufacture and they should have a rep located in your area, that can cut the red tape for you as well. In addition they may know of others with your insurance carrier that the ADR has been approved. The manufactures rep has a financial interest in getting those in the market place, as well. Not to mention they will have all the statistics your doctor will need for the appeal process. Good luck hope it all works out for you.
  • for your replies, they have been helpful for me. I've found out today that, although, my insurance will not cover the disc, they will cover the other costs associated with the surgery. I may just go that route, as I don't believe I have a whole lot of time before I have to do something for my neck. The doctor was adamant about getting me in as soon as possible and the pain, discomfort and tingling in my arm is getting worse by the day. At least I have a little light shining thru this tunnel I've been staring down. Thank you again for your help, it's very much appreciated.
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