New to the board
Hello all!! I recognize some names from another board but I'll give my background for everyone else.
I began having headaches that started in my neck back in 1997. They were severe enough that the Navy medically discharged me in 1999 with a diagnosis of tension headaches. Truthfully many of my shipmates thought i was full of sh** and just trying to get out. Thankfully the ones I worked with back in the engine room could see the pain I was in and never questioned me.
I suffered through the headaches for several years before I started developing pain in my wrists. My GP and I both thought that it was the beginning of carpal tunnel. A year or two later my left wrist began to hurt. Throughout this time I would have brief shots of pain in my shoulders and arms. I honestly thought I was imagining the pain and never disclosed it.
Finally in Jan 2007 I experienced excruciating pain in my arms, wrists, and hands when finishing my basement. I hate frigging drywall. Anyway, my GP sent me too a ortho to check for carpal tunnel. The guy spent about 30 min's with and sent me to a spine specialist.
The x-rays immediately showed thinning at C5/6 and an MRI confirmed advanced DDD. This was June 2007. The day before a follow-up with the spine ortho the prestige disc was approved by the FDA. My doc and I excitedly discussed the possibility of going with ADR over fusion. In September 2007 after PT made my pain worse I submitted a precert for ADR.
It was quickly denied and when I inquired with my employer if there was anything they could do to help me as we were self insured I was told that they could not as to make an exception for me meant they'd have to make an exception for anyone. This was October 2007 and I was regularly putting in 60-80 hour works weeks, salaried, as we were implementing an ERP package in a 24/7 manufacturing environment.
In December 2007 I accepted a new job with a new company in the hopes of getting more favorable insurance coverage. In June 2008 I got a referral to one of the best ortho spine surgeons in the southeast by a friend who is also a doc at Emory. Mainly I wanted a 2nd opinion. This doc was much more hesitant to recommend ADR. I discovered later that this was because he was involved in the development of a particular ADR and did not want to seem biased or have a conflict of interest.
Finally in December of 2008 we submitted a precert for the Prestige ADR with the hope that the Bryan disc would be approved shortly. It was denied, and denied, and denied again. At this point I engaged my new employer, making sure to point out the reduced recovery time and encouraging promise on reducing adjacent DDD since motion is maintained. The same info I gave my previous employer. My new employer is self insured also.
In short time my HR VP was asking our Aetna rep why it kept getting denied as experimental when it was FDA approved. Aetna denied the procedure again saying that the screening company, ActiveHealth, had correctly researched my issue and explained their decision.
At this point I found an Aetna policy bulletin that explicitly stated that ADR's were supported. My HR VP again demanded from Aetna how their policy could be so clear yet I be denied coverage. She was told that my case was being sent to a review board to ensure that ActiveHealth was making decisions in accordance with Aetna's policies.
3 long weeks later on the same day I let my VP know that I had sent my info to Stenum for review she emailed me back and said she was on the phone with Aetna and the denial had finally been reversed.
To make the day even better I've been told that the Bryan disc will receive FDA approval very, very soon. So I called my Dr and we'll schedule a surgery date probably in late July to give the Bryan disc a chance to get on the street and then have Aetna approve the change in device.
Sorry for the long post but I hope that it encourages some people who have initially been denied to keep fighting. I even changed companies in an effort to get more favorable coverage and it paid off for me.
Thanks,
Jason
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