BCBS of Texas

[jchebert1979]

I have BCBS of Texas (although I live in Louisiana) and this is directly from their site.

Coverage:

Cervical Disc Replacement

Artificial intervertebral cervical discs may be considered medically necessary when ALL of the following criteria are met:

Disc has the approval of the U.S. Food and Drug Administration (FDA); AND
Disc will be used for single-level reconstruction (C3-C7) following discectomy; AND
Patient has intractable radiculopathy and/or myelopathy due to herniated disc or osteophyte formation; AND
Patients has failed at least six weeks of conservative therapy; AND
Symptomatic nerve root and/or spinal cord compression documented by ALL the following:
Neck and/or arm pain; and
Functional and/or neurological deficit; and
Radiographic studies (e.g., Computed Tomography (CT), Magnetic Resonance Imaging (MRI), x-rays, etc.).
Artificial intervertebral cervical discs are considered experimental, investigational and unproven for all other indications, including multi-level use, whether done simultaneously or at different times.

Lumbar Disc Replacement

Artificial intervertebral lumbar discs are considered experimental, investigational and unproven.


This is the link to their policy. It is interesting because it even gives information that with fusion there is an increased risk of degeneration of the adjacent levels. I will be trying to get pre-approval this week. I will definately let the board know how it goes.

BCBSIL/Provider Medical Policies on Fyiblue

Just agree to terms and type in artificial disc in the search engine.

[symara]

I wonder why they are approving for Cervical, but still concider Lumbar experimental?????

[jchebert1979]

I have no idea, I thought the Lumbar discs have been around longer. At any rate, I am not giving them a chance to deny my case. I have written a full denial appeal as per "The insurance warrior's book" and worded it as a "pre-approval request". It will be sent in with my doctors pre-approval request tomorrow and I will also send a copy certified mail.

[symara]

are you requesting cervical or lumbar? Keep us updated.

[jchebert1979]

Cervical. I will def. keep everyone updated.

[symara]

I work for an insurance company and just spoke to someone, there is a possibility they may not even look at the documentation and just automatically deny it the first time. We don't know for sure, so don't take our word for it, we don't work in that area, but who knows. I just hate to think that you would do all that work and someone doesn't even look at it.

[jchebert1979]

Well the work is done and I would have had to do it anyway if they were to deny it. I realise that it could be denied off the bat which is why I put everything together in the first place. I also called my benefits department head and she said that they would help in any way possible if it were denied. I have no doubt that I will win this battle, I just need to get it over with, I am in so much pain.

[jchebert1979]

BCBS TX approved my prodisc ADR today. They recieved all of my paperwork on 4/11/09 and approved it on 4/15/09. I hope and pray that this disc is the cause of my problems.


Yeah that should have been 5/11/09 and 5/15/09, sorry.

[dridobits]

Someone please tell me if I am mistaken but according to many posts I have read, it appears that cervical ADR surgery has had more sucses than lumbar. Perhaps this was part of the reasoning.

[jchebert1979]

According to my insurance at least, lumbar ADR's are still considered experimental. I'm not sure why.