ADR & Foreign Service Benefit Plan

[jessmith07]

Hi everybody,

I'm looking for anyone in the Department of State or the Foreign Service and has Foreign Service Benefit Plan insurance (a/k/a Coventry/First Health) that was successful in getting the insurance company to pay for ADR surgery. When I first submitted for precertification, they denied it stating that the procedure wasn't FDA approved. When I provided them with the FDA approval letter, they then denied it again, claiming "there was insufficient evidence in the literature as to the efficacy of the artificial disc" and they were denying it as it is not "standard of care."

I am now trying a different route. Under HIPPA, if this insurance company has approved this surgery for anyone else under the same plan that I have, then they can't deny it to me. All I need is one person, then I can go to the Department of Insurance in my state (South Carolina) and file a grievance.

Please feel free to send me a message.



UPDATE: As I was gearing up for battle by gathering up all as much info as I could, the insurance company finally approved my surgery! I am going to find the proper forum to post all of the information that I submitted to successfully appeal an insurance denial for an ADR procedure. If we all fight and begin to win, we can make ADR the standard of care, and people will no longer have to suffer through fusions...


Thanks,
Jess

[treefrog]

Jess, I think this would probably be the right place to post whatever information you used for getting insurance to pay for your surgery.

And congratulations, again.

[jessmith07]

We used this to successfully appeal the insurance company's decision not to pay for my ADR surgery. There are a few other files that I sent to my insurance company (they are too big for me to upload, so I need to figure out how to post them)...all of which is what I sent in my final appeal (I was denied twice before I sent this information). Three of these items I found on Dr. Bertagnoli's website, I don't remember where I found the other two, and the following is the 2007 study that my husband paid $40 for on one of those Pay-per-view medical sites:


Survivorship Analysis of the Charité Artificial Disc: Review of 1,938 Patients from Eight Leading International Spine Centers

Bryan W. Cunningham MSc1, George Demuth MSc2, Paul C. McAfee MD3, Matthew Scott-Young MD4, Kj Yoon MD5, Scott Blumenthal MD6, Richard D. Guyer MD6, Fred Geisler MD7, John Regan MD8, Bart Conix MD9, Robert Hes MD9, Luiz Pimenta MD10, Roberto Diaz MD11, Ira L. Fedder MD12 and P. Justin Tortolani MD13

1St. Joseph Medical Center, Towson, MD, USA
2NC, USA
3St. Joseph Hospital, Towson, MD, USA
4Southport, Queensland, Australia
5seoul, South Korea
6Texas Back Institute, Plano, TX, USA
7Chicago, IL, USA
8Beverly Hills, CA, USA
9AZ middleheim hospital, Antwerpen, Belgium
10Sao Paolo, Brazil
11Sao Paulo, Brazil
12Spine and Scoliosis Center, Towson, MD, USA
13MD, USA

PURPOSE: The current investigation reviews data from 1,938 Charité Artificial Disc patients at eight international spine centers and examines the incidence of surgical revision at the index and adjacent levels.

STUDY DESIGN/SETTING: Patients from eight leading international spine centers were evaluated in this study.

PATIENT SAMPLE: A total of 1,938 patients served as the basis for this study.

OUTCOME MEASURES: Surgical revision, reoperation or implant at the index and adjacent levels.

METHODS: A total of 1,938 patients were included in this analysis. 305 patients from the United States were all single level reconstructions and included those randomized in the Charité Food and Drug Administration Investigational Device Exemption and continued access studies. 1,633 patients from Australia, Korea, Belgium and Brazil all received single or multilevel Charité Disc implantations (two to four levels). Survival of the prosthesis was defined as absence of implant revision and re-operation at the index level, including removal of the prosthesis. Any incidence of surgical re-intervention at the adjacent level(s) was also compared to ALIF controls (n=58). Patient populations were divided into five groups -United States, Australia, Korea, Belgium, and Brazil - and tabulated in terms of total patient number, reoperative rate, mean overall follow-up, and mean follow-up at revision. For each group, Kaplan-Meier estimates were provided for the time to revision. For individual sites and the overall plot of subjects, the 95% lower two-sided bound was used as obtained from Peto's adjusted standard error. Patients were further grouped into postoperative time intervals of less than or greater than 2 years follow-up. A likelihood ratio chi-square test was performed on each subset to determine whether an association existed between clinical failure and the number of months to follow-up.

RESULTS: Mean follow up was 23 months. The 5-year predicted survivorship for the Charité Artificial Disc (without revision, reoperation, or removal) ranged from 91.6% (Brazil) to 96.2% (Korea), with an average of 93.1%. This compares with 80.1% for ALIF with BAK cages. The lower confidence limit for Charité Artificial Disc survival was 87.7%, and the lower confidence limit for lumbar fusion was 51.5%, which is highly significant (p=0.0034). The predicted five-year survivorship for the adjacent levels in Charité cases averaged 95.6%, with 19/1938 cases requiring surgical reintervention. This compares with 89.0% survivorship for ALIF with BAK cages at the same time interval, which was significantly different (p=0.035). The likelihood ratio test suggests that a statistically significant association exists with clinical failure occurring early postoperatively if it occurs (p=0.020).

CONCLUSIONS: This investigation is the first international, long-term survivorship analysis conducted on the Charité Artificial Disc. The 5-year predicted survivorship for the Charité, based on patient return to the operating room, is 93.1%. Moreover, the frequency of surgical reintervention and revision at the index level following Charité Artificial Disc reconstruction is significantly greater within the first 2-year postoperative interval than at 2 to 8 years postoperatively.

FDA DEVICE/DRUG STATUS: Charité Artificial Disc: Approved for this indication.

[jezzicaz789]

Originally Posted by jessmith07

Hi everybody,

I'm looking for anyone in the Department of State or the Foreign Service and has Foreign Service Benefit Plan insurance (a/k/a Coventry/First Health) that was successful in getting the insurance company to pay for ADR surgery. When I first submitted for precertification, they denied it stating that the procedure wasn't FDA approved. When I provided them with the FDA approval letter, they then denied it again, claiming "there was insufficient evidence in the literature as to the efficacy of the artificial disc" and they were denying it as it is not "standard of care."

I am now trying a different route. Under HIPPA, if this insurance company has approved this surgery for anyone else under the same plan that I have, then they can't deny it to me. All I need is one person, then I can go to the Department of Insurance in my state (South Carolina) and file a grievance.

Please feel free to send me a message.



UPDATE: As I was gearing up for battle by gathering up all as much info as I could, the insurance company finally approved my surgery! I am going to find the proper forum to post all of the information that I submitted to successfully appeal an insurance denial for an ADR procedure. If we all fight and begin to win, we can make ADR the standard of care, and people will no longer have to suffer through fusions...


Thanks,
Jess

Thank you for the post.
Hi guys, Im a newbie. Nice to join this forum.

[dshobbies]

Hey J,

Welcome to the forum! Please start a new thread and tell us about yourself.

Do you get insurance approval for an ADR???

Dale