Proc Disc C Insurance Approval

JH

My Doctor has recommened I get pro disc C surgery at two levels. This after many years of pain and other treatments.
He sent a request for approval to my insurance company Anthem/Blue Cross of California (now don't laugh). They denied the surgey saying it is experimental. I filed all the appeals and got their standard denial form letters back. Has anyone else had this issue with them? If so did you over come it. Their own policy says if the FDA has approved something they can not call it experimental, but yet they do as they please. Any help on how to get them to approve the pro disc c surgery would be great. I will continue to live with the pain before I get the fusion surgery, of course that is what they are probably hoping for???

steve55

Google "laurie Todd the insurance warrior". Her book is only $15 and it will show you how to win your appeal. I know of many people who got blue cross/blue shield to pay for their 2 and 3 level ADR surgery. I have proof of one approval letter showing they have approved it before. Your appeal is solid if you can collect insurance approvals showing they have covered it before. Laurie explains in her book that insurance co's call even FDA approved procedures experimental. They say that all the time with expensive procedures hoping the patient will just go away. Get the book. Also visit the ADR support forum, you'll learn so much more there.

JH

steve55

Thanks for your response and for the info on Laurie Todd. I went to her web site and will follow-up with her suggestions/process for an appeal.

JH

ouch

I was denied 3 times ADR surgery through my insurance company. Finally, I hired an attorney who got me an AME appointment. The AME said, "I will authorize this surgery if you kick and scream, but I don't recommend it at all." Supposedly, the theory is good, but finding a competent doctor to do it is very hard here in the USA. He told me that I would be a guinnea pig and that there are no long term studies proving ADR efficacy. I have heard the surgery is only as good as the doctor, and if they haven't done tons of these surgeries, it can mess you up badly. So, I gave up knowing that there weren't any doctors in my area that had done a ton of ADRs. I was considering going to Germany and paying out of pocket (Dr. EDITED sp? in Germany is the most experienced in the world I hear). But, I just decided to be conservative and stick with a fusion. I still have a lot of pain and I am willing to bet the other levels in my spine are stressed big time. Good luck in your decision. May you get the ultimate in care and your future look pain free! Let me know how it goes!
ouch

Doctors name and contact details removed by forum Moderator (paulgla). We do not permit publishing specific doctor's or institution names and contact details.

JH

Ouch, Thanks for taking the time to respond to my posting. It is a tough choice I know. I have a good Dr. at UCSF and am willing to go for it. I am still fairly young and need to continue to work and without pain if possible. Plus I figure they are now using the pro disc c on NFL football players and they are returning to the field to play. I'm no NFL player, but that is the direction I need to go in.

ouch

That is exciting news that they are doing ADRs on NFL players. ADRs are looking more and more the wave of the future. Thanks for letting me know! Let me know how it goes for you. I may very well make the same choice if other levels go bad.
ouch

JKDE302

ouch said:

That is exciting news that they are doing ADRs on NFL players. ADRs are looking more and more the wave of the future.

wow r u serious? I need to look this up...Pro athletes coming back to sports after ADRs?????????????

JKDE302

JH said:

Plus I figure they are now using the pro disc c on NFL football players and they are returning to the field to play. I'm no NFL player, but that is the direction I need to go in.

WOW WOW WOW

JH

One of my big issue's is being able to go back to work and needing to go back to work after my surgery wether it is the fusion or the ADR. My surgeon said, I guess to make his point about being able to go back to work, that if all goes as planned (knowing with any surgery thing can happen) that normally NFL players can have a two level fusion and still be approved to go back to playing ball. He said he knows ADR's have been used on NFL players and they have gone back to playing ball. Of course he would not give me the scoop on who and I have not been able to find out who has, but I have no reason to not believe the surgeon? He does work in a hosptial that services two NFL football teams.

JKDE302

That is good news I wonder if ADR will replace fusion in a few years..why would anyone have fusion when they could have an ADR?

JKDE302

my friend came over for 420 last night who plays in the NFL and said his trainer had an ADR in the neck and was back to work in 2 weeks.