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Anthem BCBS denied Hybrid Alif/adr

quarterbunnyqquarterbunny Posts: 4
edited 06/13/2014 - 4:14 AM in Health Insurance Issues
So as the title states.... Anthem BCBS denied the surgery my doctor wants to do, a Hybrid ALIF/ADR. I got those terrible words "Not Medically Necessary"

Without this surgery to get my spine stable, and away from the nerves.... I am looking at my entire lower half becoming paralyzed from the pressure on my nerves.... The doctor can't even do each portion, the insurance will only cover a single level fusion or a disc replacement... but not both, and not separate surgeries.

I am crushed... I am only 30, and I am looking at spending the rest of my life in a wheelchair.... and all because an insurance company wants to line it's pockets.


  • ADR put in, along with a fusion is not a generally recommended procedure, by the manufacturer's nor by most surgeons. How many surgeons have you consulted with? What other options have they recommended aside from this particular sugery? Have you gone to any major medical centers to see any of the top specialists there?
    The reason that I am asking, is that while I don't know the particulars of your situation, if another doctor agreed with the diagnosis and the outcome if you didn't have surgery, you would have a second or third surgeon who agreed and may help the appeal for the approval, but if not, then you may find that you have other options for sugery that don't include a double procedure and still preserve your ability to walk.
    It is something to consider.
  • I feel ur pain too. I have BCBS Delaware. They will not approve TDR, but will disk fusion of L5-S1. I have been holding off now for 5 yrs. Steroid injections only last about a week or two before the pain returns.

    Did you do the internal and external appeals? You have the right to, so it's worth a shot.
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  • I can't believe the difficulties you guys have with insurance. It must be soul destroying.
    I've had a very successful ALIF/ADR and although it has taken over a year to feel recovered, I'm glad I had it done.
    I have private insurance cover here in Australia and if the surgeon recommends a certain surgery you just go ahead and have it done. You don't notify your insurance company in advance and they don't have a say in the matter, Your surgeon gives you a rough estimate of out of pocket costs and the insurance company pay up, no questions asked.
    I hope you get the surgery you need without all the headache of insurance company hassle.
    DDD. Married,Mum of 2, Age 45: 2007 & 2008 L5/S1 Discectomy
    April 2013 L5/S1 Anterior Fusion
    & L4/L5 Artificial Disc Replacement
  • jlrfryejjlrfrye ohioPosts: 1,111
    it sounds as if your Dr needs to send more documentation. Along with that you also have to appeal the decision, Ask for a expedited appeal so the process doesnt take as long, Tell them they are causing UN-necarry pain and suffering. This will qualify for a expedited appeal which should cut the time for a decision in half, Make sure you have copies of all your medical records and send them with the appeal'
    good luck
  • You can also contact the manufacturer of the ADR and get supporting documents from them. They were a big help for me.
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