L5/S1 ADR Coverage

Eastex · #1 (**permalink**) 10-29-2008, 06:57 PM

Hello everybody, my name is Greg. I am so glad I have found this forum. I have already seen a lot of my questions answered. I have been experiencing lower back pain for about 8 years. In the last year, it has intensified to the point of taking pain meds, Chiropractic, MRI ,3 Injections and PT prescribed by a Neuro doctor. Nothing has helped! The MRI showed posterior annular tear and herniated L5/S1 disc. This doctor is known around here for being good and said he didn't see the need for surgery. I will also add that he is very cocky too. I have a friend who has a relative that works for another surgeon and he said that I need surgery and I am the perfect candidate for Charite ADR. I agreed and now have been told by United Health care that this surgery is "experimental" and is not covered. I am waiting on the doctor to discuss this with their physician reviewer. Am I going down the right path? Has anyone had any luck with United Health care on ADR? Is a fusion my only option now?

dshobbies · #2 (**permalink**) 10-29-2008, 07:09 PM

Hi Greg and welcome to the forum,

I'm sorry for your pain and what you've already discovered as the slippery slope of the medical world pertaining to spine patients. Fortunately you found us and we're here to help.

Very few people have manged to get their ADR surgery covered by any insurance company, the emphasis on very few. Is it worth your trying or is it a waste of your time? Who knows. I view it as a lesson in futility. Chances are if you do want to go ahead with ADR surgery, you'll have to pay for it yourself.

If you do decide to go ahead, you should find a doctor who knows what he's doing, someone who has performed many of them. You already know different doctors have differing opinions. You should also become informed as to other remedies available to you as well as other artificial discs.

Do your homework, ask questions, make informed decisions.

I wish you good luck,

Dale

Eddie G · #3 (**permalink**) 11-02-2008, 04:25 AM

L5-S1 isn't the worst level to have a fusion. That level doesn't move like the L5-L4-L3 levels so I wouldn't sweat it if you cant get ADR. I may get a fusion at L5-S1 also.

Eastex · #4 (**permalink**) 11-03-2008, 05:56 PM

I finally heard that the doctor was going to talk to the insurance company Friday. He has been sick and behind on surgeries and hasn't been able to reach the right person to talk to. He feels confident that after he talks to them they will approve it. I should find out something today. I have called to see, but I am waiting on the call back since was busy at the time. If it is still a no go, I will go for the fusion. I am tired of the pain. I haven't studied the fusion surgeries too much. Isn't the recovery longer and will I have to go back and have more fusions? I have heard that once you get one it loads up the other discs and causes more problems. I am only 32 and employed as a crude oil pipeline mechanic. I don't want to end my career!!

dshobbies · #5 (**permalink**) 11-03-2008, 08:49 PM

Your concern for fusion surgery is valid. Yes, it does have a longer recovery time and yes, it can and often does promote DDD at adjacent segments, so yes, it can crawl up your spine. The hardware too can cause it's own problems, something else you might want to investigate. The screws can come loose and another surgery to remove them may also become necessary down the line.

However, ADR surgery is no walk in the park either. First, there is also the possibility of promoting DDD at adjacent segments over a longer period of time but there hasn't been much study or talk about it. Not too many people have had them for that long. A study along those lines might prove interesting.

So yes, I realize that finances are more than a problem for most but your health is not something on which you should settle, especially at such a young age. But then again, maybe you've got a shot at insurance coverage.

Good luck, Dale

Jim M2 · #6 (**permalink**) 11-04-2008, 05:11 AM

I'm pretty sure a single level Charite was approved in 2004. I don't know why your insurance says it's experimental. They're using their own arbitrary definition of experimental. Fusion is not a bad choice. I have a L5-S1 Charite. It got rid of my disc pain but caused facet pain that was just as bad as the disc pain.

Eastex · #7 (**permalink**) 11-04-2008, 06:56 PM

Yes, I have seen that it was approved by the FDA in 2004 also. I think they are concerned since it is still kind of new and the long term effects are in question. I could see that your facet pain may be what they could be concerned about. I have heard that BC/BS and Cigna will allow the surgery. I talked to doctors office this morning and told them i will go to Dallas soon if they don't let me know something. It just bothers me when someone says they will call you and they don't. At least call me and tell me that the doctor still hasn't been able to talk to the insurance company yet! I left one doctor already because of this treatment. I am just frustrated and had to vent a little. I had to replace a pump today and it took me forever because of the pain. I take Hydrocodone and Soma to at work to keep me moving. But, it seems to not work that good anymore.

Jim M2 · #8 (**permalink**) 11-05-2008, 07:39 PM

Greg,

I don't know how you continue to work at all. I know what you're saying, pain killers don't even take the edge off and it's even worse when you're aggravating it by lifting, stooping and the like. Someday when you look back you'll wonder "what the heck was I doing working?" It's self inflicted torture because the medical community, employers and people in general have no idea what we go through. We torture ourselves because of their expectations and the resulting rules of the game that don't allow us to stop because of loss of income, insurance and employment. Another reason we torture ourselves is because of our own self doubt about what we are experiencing. Our perception of ourselves is through others and they look at us and say things about us not looking injured, or suggest we ignore it as if it's a minor discomfort. I thought I was going insane until I stumbled across the forums.

If I were going through it again I would probably opt to tough it out. I was collapsing gracefully. By gracefully I mean my spine was stable and I would have probably auto-fused with loss of most pain. If you have a job working pipelines this isn't hardly an option. If I were to opt for surgery route I would go for L5S1 fusion. This is biased hindsight because I have had a bad experience with ADR.

Eastex · #9 (**permalink**) 11-05-2008, 11:05 PM

Well I am at the house today. It took just about all morning to be able to get out of bed. I am glad my bathroom is close to the bed! I am in so much pain from doing a little too much yesterday. Jim, I see what you mean. If I ever here anything from my doctor and insurance company, I may do the fusion. Did you have better luck with ice or heat? Of course, I mean with a heavy dose of pain meds. The heat seems to make the bones ache. I had a chiropractor tell me to use ice because I need "to cool off the inflammation". Another question that I have is has anyone had surgery done in Dallas area or at The Texas Spine and Joint Hospital in Tyler, TX?

mmglobal · #10 (**permalink**) 11-06-2008, 05:54 PM

Heat vs. Ice? Intuitively, it would seem that heat would increase the inflammation. Unless you are in the camp that believes that heat increases bloodflow, therefore increasing healing. It also makes you feel 'warm and loose', relaxing you.

I think the heat / ice question is best settled in one of 2 ways.

1. What does your doc say? You'll want to be compliant if she has strong feeling about which is better.

2. What works best for you. I know many people who swear by both... but I think I know more who prefer ice.

BTW, Dr. Kevin Pauza is a the Tx Spine and Joint Hospital in Tyler. He's involved in many new technologies that are quite promising.

Good luck! Please keep us posted,

Mark

Eastex · #11 (**permalink**) 11-06-2008, 06:30 PM

I went and picked up a copy of my MRI today and I am sending it to the Spine and Joint Hospital in Tyler. I am not sure if the doctor I am currently dealing with is taking the time to do a pier to pier with my insurance company. I guess it wouldn't hurt to get a third opinion.

Dreamy · #12 (**permalink**) 11-07-2008, 03:39 AM

I’m new to this site. My name is Jamie and I live in Ft. Lauderdale, FL. Like Greg said, I am so happy to have found this site! I have been going though pure hell the worst 4 years of my life with this back issue. Like everyone else I have issues w/the L5/S1 no disk at all left just bone on bone. I have tried everything from Physical Therapy to Acupuncture to the Injections (of every kind) to Discectomy and nothing has helped. I have been in pain mgmt for the past 3 years I am on enough drugs to knock down a Horse, yet the drugs don't even help anymore! I think about just stop taking them, but then I am so afraid that if I do I really may not be able to move. I have been to Dr. after Dr. and then they tell you crap like "you will just have to learn to live with it"! I can honestly say that until a couple months ago I was HOPELESS!!!! I was done really ready to throw in the towel! I am only 38 years old but I have the back for a 100 yr. old. So as a last ditch effort I went to see a “Spine Specialist” who actually seemed like he might know what he was talking about. He ordered a bunch of tests as well including the most barbaric of them all the Discogram (I thought I was going to dye!!!) they couldn’t even get the needle in. So after that I went back to take to him and said that my only op. was surgery, or to live w/it. So we starting talking and the only surgery he does his Fusion, but he is very close with a college that does the ADR. So we talked about the Fusion and then he told me listen, I want you to go and meet with Dr. Garcia, he even called his office to see if they accepted my Insurance, and of course they didn’t….lol but, he got him to meet with me anyway. So about a month ago I went and meet w/Dr. Garcia and learned about Disk Replacement and not only that but I was a perfect candidate for a clinical trial to have the Disk put.

So after reading as much as humanly possible talking w/both Dr. Garcia & my other Dr. and my kids and having really nothing to loose I have decided to have the Disk Replacement done on the 19th of this month. I am scared to death, but I am even more scared of not having this done!

So if anyone could let me know if you have had this done and what I am looking at as far as recovery time, pain, just anything & everything at all, I would really appreciate any feedback. I am so nervous & scared yet I am so excited to get my life back. This has affected EVERY SINGLE part of my life!

I look forward to hearing from any of you soon.

Thanks,

Jamie

Eastex · #13 (**permalink**) 11-09-2008, 08:00 PM

Wow!! It seems every Doctor in my area can't return phone calls. I am trying Texas spine and joint hospital, but it seems the person I was told to talk to is off or something. My brother had his shoulder done in Dallas and wants me to go there to the spine specialist. The name is WB memorial clinic, I think. I will try to locate them also. I am leaning toward TS&JH because I see they were rated #1 in Texas by health grades. Maybe, Monday I will here something from someone.

dshobbies · #14 (**permalink**) 11-10-2008, 05:23 PM

I found Mark because of non-returned phone calls. It has epidemic proportions!

Good luck.

Maria · #15 (**permalink**) 11-10-2008, 08:29 PM

I initially called their secretaries or administrative assistants to find out what these doctors offered in terms of services. Many of these people were willing to talk to me which I found helpful.

Most helpful has been the assistance Mark has provided me in getting opinions and consultations and even accompanying me to the dreaded WC 2nd surgical consultation as well as another major WC (Workers Compensation) appt.

Good luck. It's scary to be in this spinal mess but it's great when there's someone out there that can help navigate thru the spinal maze.

This forum is a good resource place as are a few others. For information/education please check out ChiroGeek's Home Page

Jim M2 · #16 (**permalink**) 11-11-2008, 07:03 AM

Greg,
Congrats on doing your homework and continuing to look for responsive doctors. My OSS has a Physicians Assistant who is very knowledgeable and responsive by phone and email. If she doesn't have an answer, she'll consult with the doc and get back to me. It's hard to find a better setup because these doctors, with rare exceptions, just won't make the time for us.

Eastex · #17 (**permalink**) 11-11-2008, 05:38 PM

I have made an appointment with Dr. Dossett with the WB Carrell Clinic in Dallas. He is the spine specialist for the Texas Rangers, Dallas Cowboys and many others teams. It isn't until 12/1, but I have hope and I think I will be better off in the big city. My brother had shoulder surgery there and is doing fine. He was butchered on by a Longview doctor and he had to go there for it to be corrected. I still never heard from Texas Spine and Joint Hospital, so I decided to proceed in my search. I will just stay with my ice and vicodin till then. I can't miss much more work. It is very hard to ride in my truck for long distances. A one ton truck isn't good on a spine. I try to do as least as possible. Thank god that I have another mechanic that can handle the hard stuff. Yesterday, I had to climb the stairs on one of our crude tanks and my back, hips and legs were killing me. I feel like they think I am lying about my back because every time I am told by a doctor that something is about to be done, it falls through. What type of pain meds do the fellow forum users recommend?

Eastex · #18 (**permalink**) 11-12-2008, 09:50 PM

I just received a call from the office of the surgeon that wanted to do the ADR. They told me he has an appointment to talk to my insurance tomorrow about the surgery. I have heard this before, so I am not really looking for getting that call. I have moved on to making appointments with others now. What to do, what to do! I have talked to Mark before this and we were moving along.

mmglobal · #19 (**permalink**) 11-13-2008, 04:46 PM

Continuing to do heavy work with disc bulges pressing on nerves can be risky. If you really blow something out, permanent damage can be done. Be very careful.

Eastex · #20 (**permalink**) 11-13-2008, 06:36 PM

Actually received the call from the doctor. He said United Healthcare is going to probably be approving ADR surgeries in the next 5-6 months. He is going to file an appeal still. He advised to wait till the approval if I can. He said since I have made it this long I could do it. I am getting worse everyday. Like Mark said, it is probably the work I do. I come home and get in my recliner or bed on ice packs. I try to be careful and all of the other employees stop and help me. I really appreciate them and my wife and the help I am receiving here. I am still proceeding with my other options in Tyler and Dallas.

Eastex · #21 (**permalink**) 12-04-2008, 09:52 PM

Well I went to see the great Dr. of the Texas sports teams in Dallas Monday. I was told to go back to PT for 6 months and then come back if needed. I have been here and done this crap. The only difference is that he prescribed his book to follow during the PT. His book is a handout with almost the same stuff I have done in the past. Texas Spine and Joint here I come! I have to wait another month to get in to see them. I hope this isn't a waste of time like the Dallas Doctor.