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Appeal process is beginning, but I am in incredible pain!

2

Comments

  • Online indicates the 9 codes relating to emg or neuromonitoring. The monitoring doesn't seem to be covered yet. The 2 codes should be. I was pretty determined to wait for ADR and ended up not being a candidate for it. I think it's because I lost all curvature and had three bad levels.

  • sara.g said:


    My surgeon advised me that almost all of the time this is offered, that the insurance will refuse to pay afterwards. That insurance considers it as they approved one level only, and did not approve the two level surgery to take place. I don't know how to communicate this as well as my surgeon's office, but everyone else I've spoken to about this idea has said that there would be a post-surgery denial.

    I would love to pay for the second level myself. Are you saying that you had a 3 level disc issue?

    Actually, I had herniations at 5 levels (every level other than Occiput - C2 and C7-T1).  I recently had C6-C7 fused.  One opinion wanted to fuse C5-C7 and put an artificial disc at C4-C5.  I didn't go with that opinion because my pain management doctor's opinion was that it was too radical and that I could always go back in and do adjacent levels, but you can't undo what is already done.  Three of my 5 opinions only wanted to fuse one level; one guy wanted to fuse two levels and the third guy wanted to fuse two levels and do an artificial disc above.

    Your surgeon is possibly correct that the whole surgery could be denied if they only approve one level and you get two levels done.  Not sure how the surgeon who wanted to do a three level, with ADR at one level, was going to go about it with insurance, but perhaps he was going to get a three-level ACDF approved and then just sneak in an artificial disc at one level , for which I would pay $5,000 cash.  I absolutely would have done it if I thought it was a good decision for me medically, but I just wasn't convinced.
    C6-C7 ACDF - January 20, 2016
    Shoulder surgery - August 2, 2016
    Interlaminar laminotomy, mesial facetectomy and foraminotomy bilateral at C5-C6 and unilateral left at C6-C7 and bilateral C6-C7 facet fusion - December 7, 2016

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  • sara.g said:


    In the meantime, which could be months, I am very concerned over what I should do about my pain level. I feel like someone is torturing me with hand tools on my neck, it is truly awful. I am on a lot of meds at this point because it has been quite awhile now that I have been dealing with this. I am frustrated. I feel like nothing is really helping me anymore. 

    Trust me, I feel for you.  Your description of feeling like someone was torturing you with hand tools on your neck sums up how I felt before surgery. It took me quite awhile to find a surgeon because I started looking in October and it seems like fall is "busy season" for spine surgery as everyone has met their deductibles for the year and wants to have surgery by year end.  It took me 6 to 8 weeks just to get consults and everyone was too busy to do the surgery last year because there were people stacked up before me.

    I coped with neck pain for years through a combination of yoga, acupuncture and massage, but at the end, they just didn't help at all, with the exception of one passive yoga position which put my neck in traction which helped a little.

    I didn't try steroid injections, but that is something you might want to look into, not as a substitute for surgery, but perhaps to give you a bit of relief while you try to sort through the insurance issues.
    C6-C7 ACDF - January 20, 2016
    Shoulder surgery - August 2, 2016
    Interlaminar laminotomy, mesial facetectomy and foraminotomy bilateral at C5-C6 and unilateral left at C6-C7 and bilateral C6-C7 facet fusion - December 7, 2016

  • sara.gsara.g CaliforniaPosts: 45
    I just want to update that my appeals all ended in a final denial via my California Board of Insurance external appeal. However, my some sort of insane luck, my insurance changed their policy on 2-level disc replacements and I will have my surgery next month.  I do not know how to explain this sort of luck. But I am definitely going to church this weekend.  Now I am mostly concerned about how the surgery will be for me. 

  • sara.g said:

    I just want to update that my appeals all ended in a final denial via my California Board of Insurance external appeal. However, my some sort of insane luck, my insurance changed their policy on 2-level disc replacements and I will have my surgery next month.  I do not know how to explain this sort of luck. But I am definitely going to church this weekend.  Now I am mostly concerned about how the surgery will be for me. 

    That's great to hear! Did you have the surgery? How did it go? I just learned today that I need two level disc replacement at C4-5 & C6-7. I have Aetna insurance & my surgeon said that they usually deny the surgery as experimental. Any tips on getting Aetna to cover a two level disc replacement?
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  • sara.gsara.g CaliforniaPosts: 45
    Txpenelope!!!! Have your surgeons office resubmit!! Aetna covers 2-level ADR NOW!! I literally got through all my appeals and went through Extermal Review with the board of insurance and got a denial. On July 8th, Aetna changed their policy on 2-level ADRs during their yearly review. I hope this helps you!! 
  • sara.gsara.g CaliforniaPosts: 45
    I still need to have the surgery but the surgeons office won't schedule until August. 
  • Ellen625EEllen625 New Jersey, USPosts: 757
    Great news Sara! I hope it goes well. At least this part is a relief! 
  • sara.gsara.g CaliforniaPosts: 45
    Thank you!!! I believe it is a miracle and am definitely going to church tomorrow. 

  • sara.g said:

    Txpenelope!!!! Have your surgeons office resubmit!! Aetna covers 2-level ADR NOW!! I literally got through all my appeals and went through Extermal Review with the board of insurance and got a denial. On July 8th, Aetna changed their policy on 2-level ADRs during their yearly review. I hope this helps you!! 

    Where can I find documentation of the July 8th policy change??? Need asap. 
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