Coverage declined due to prior surgery - options?

jmichaelp

So 12 days before scheduled two level cervical disk replacement surgery I find out that my 2011 cervical foraminotomy means that this will not be covered by my current insurance company. I contacted Mobi-C & they said no other insurance company will cover it. I suppose I can get a fusion, but in looking at my neck x-ray/MRI I'd bet adjacent levels would follow. I can pay out of pocket but that's probably $30k unless I can get a discount from the hospital. Does anyone know what the typical discount is? I guess I could go out of the Country & pay out of pocket. Does anyone have experience with this, both in how to do it as well as cost? Thanks.

L4_L5

Can you appeal?

jmichaelp

I'm going to try to appeal. I'm looking for total disk replacement statistics when there was prior surgery. I contacted Mobi-C manufacturer who told me that they didn't conduct studies with previous surgery when getting FDA approval, so it's probably going to be hard to find. I've read so much about disk replacement having better results than ACDF so I don't know why insurance companies push patients to ACDF.

AJGormit

Good luck with your appeal @jmichaelp

If you want to access old posts about this subject, you could use the search box at the top of the page and then scroll down to Spine-health articles or alternatively, you could read old post in the Surgery Buddy groups.

 This link has information about disc replacement.

https://www.spine-health.com/treatment/artificial-disc-replacement/lumbar-artificial-disc-replacement-chronic-back-pain

Please update us on your appeal

Take care

AJ

EMS Guy

Wow, I'm sorry to hear they did that to you.  There are a couple things you can try, but no guarantee it will work.  First, start with your doctor and ask if he will do the procedure for the same amount of reimbursement the insurance company would have paid.  Most all hospitals and doctors charge something like $50,000.00, but settle on a negotiated rate of $20,000.00 depending on the coverage you have. (Estimated numbers)

Smaller insurance companies don't usually get the same break larger companies have.  That's because the larger group has more patients, therefore make more money off of volume. 

This one may scare you a bit, but it's safe.  Check with your local "learning hospital" (affiliated with University Medical School).  See if they have any trials upcoming regarding equipment.  Plus, see if you could enter a program where your case will be used for learning.  In other words, student physicians assist the primary surgeon so they can learn the procedure.  You may get a discounted rate.

kpsnap

So unfortunate that insurance coverage can be the limiting factor. My disc replacement surgery was denied initially but eventually approved after my surgeon appealed and I called the medical director of my insurance company and left a long, emotional message. Keep trying and good luck.

jmichaelp

Update.

The first surgeon blew me off - wouldn't answer emails or help to fight the insurance company. I started having more problems with my gait & handwriting due to spinal cord  impingement. So, I went to another surgeon & got the fusion.

I got to the 4 month of recovery where everyone really starts to feel better, but it started to go downhill after that. Today's 6 month x-ray showed a cage had moved, so it looks like another surgery.

memerainbolt

Thanks for the update, it's been a while. Are you going with the same surgeon that did the fusion? I hate to hear this, keep us updated.

jmichaelp

This surgeon has excellent reviews but I'll try to find another for a 2nd opinion. I told both surgeons that fusion wouldn't be good b/c compensating for bad problems w/ my lower back could cause me to stress my neck & vice versa. Now my lower back is also much worse & I'm not sure how I'll get through another neck surgery.

memerainbolt

A second, or even third, opinions are the way to go, if you can. But which is first, your neck or your back?