[Kathy]

And I'm denied. I am posting the denial letter that they sent me word for word, it is in italics. They brought up my age, 28, as a reason for denial; umm thought you couldn't discriminate based on age? I am so mad, what am I paying them $850 a month for again? I am also hoping that someone can point me to information that disproves their stance. I sent the FDA approval letter, 2 seperate letters of medical necessity and 5 different clinical trial articles.
Here is the denial:

Type of Sevice: Lumbar Artificial Intervertebral Disc
CPT: 22857
Review Outcome: Non-Certification

APPEAL
We have competed our review of the appeal you submitted for the requested service.

The service listed above has not been certified because it is considered experimental or investigational. Please refer to the plan provision entitled "Experimental" and/or "Investigational" in the subscriber's plan materials. On appeal, all clinical infomation submitted in relation to this requested service was reviewed by an independent physician board certified in Orthopedics who was not involved in the initial determination. Non-certification for the requested service is based on the following criteria and clinical rationale. Although artificial disc replacement (ADR) implants are FDA approved and recent clinical results are encouraging, the data is still preliminary. Lumbar ADR is certainly one of the most innovative and exciting developments to come along in spine surgery. It is thought that ADR can preserve motion segments in the lumbar spine, which will ultimately minimize adjacent level degenerative changes that are seen with lumbar fusion; however, the long-term benefits of ADR in preventing adjacent level disc degeneration have yet to be realized, and there is little information concerning patient outcomes and implant survivorship (Eur J Spine 2006). Moreover, complications of total disc replacement may not be known for many years, and given your young age; it is likely that you will require revision procedures in the future. While ADR is being utilized in the orthopedic spine and neurosurgical communities, further prospective, randomized controlled trials with longer-term follow-up are needed before these devices are implanted on a widespread basis.

This determination is not a recommendation for treatment. This review addresses the efficacy of the service(s) as determined by the applicable provisions of the health benefit plan. The decision regarding what treatment is best remains with the member and the healthcare provider.

Upon request, you may recive free of charge, a copy of the clinical rationale as well as any guidelines used in making this determination.

This completes the internal Appeal process.

I addressed all these things with the clinical trial information I sent. They state one source, I sent 5. It is frustrating that they can just ignore the information and cherry pick their's to base their denial on! I am not sure if I will appeal again, doubt I will get an approval. I have never heard of Unicare paying for ADR. I love how they add that the decision lies with the provider and patient.... yeah if you got lots of money to pay cash for it! I will probably just be in the Freedom Disc Clinical Trial, if and when it starts.
Kathy