L5/S1 ADR Coverage

Eastex · #1 (**permalink**) 10-29-2008, 05:57 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, 06:09 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, 03:25 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, 04:56 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, 07:49 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, 04:11 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, 05:56 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, 06:39 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.