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BCBS Carefirst of MD denied Cervical ADR 3x

AnonymousUserAAnonymousUser Posts: 49,578
edited 06/11/2012 - 7:24 AM in Health Insurance Issues
I am a 38 y.o. self-employed female who has been diagnosed with a c5/6 herniated disc with spinal cord compression. My symptoms are more c6/7 nerve root but I have been told that is fairly common. I am desparately trying to get the Presige ADR approved by BCBS Carefirst of MD. I have a great indemnity policy so I can see as many or whichever specialist I choose.

I have no history of neck or spine issues. I awoke on May 23, 2008 feeling like I had slept funny. By the evening I had a pulsating pain going down my back from my right shoulder and down my right arm. I spent all day Saturday & Sunday in bed crying in pain. Luckily my father is a physican so he prescribed me prendisone, Flexeril and Percocet to help me survive until I could get into see a physician. Unfortunately, it was Memorial Day weekend and most offices were closed Monday. On Tuesday, the prendisone had kicked in and I was able to see and Orthopedic Surgeon. He took x-rays and did an exam. The x-rays showed mild narrowing c5/g and he documented some c6/7 radiculopathic parethesias. He recommended I continue the medication with modification and start PT. I completed 4 months of PT including mechanical traction, electrical stimulation, manual massage and exercise. I felt better and close to normal. However, that only lasted two weeks.

The pain began again October 7, 2008. I went for an MRI. It showed c5/6 herniation w/ spinal cord compression & signal change. I went to two Neurosurgeons who both said surgery is the only option. Both are very conservative and said if I had not already done PT, they would have recommended it as a first measure. The second is a little younger (late 40's early 50's) and suggested Prestige ADR as an option to ACDF since I was young and was an ideal candidate.

Over the past month, I have been through three levels of appeals at BCBS Carefirst of MD. My physician had a peer-to-peer w/ a pediatrician (like that makes any sense). I am now appealing it with the MD Insurance Commissioners office. I am collecting data regarding other insurance plans that have approved ADR so I can submit it with the appeal. I am self-employed with no disability insurance. I can not afford to take off the time required to recover from ACDF surgery. ADR surgery has a much shorter recovery time, you don't lose mobility and has the potential to put less pressure/wear on the discs adjacent to the fusion. Any advice, suggestions or empathy you can provide is welcomed.


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