Got my answer to my insurance appeal...

[Kathy]

And I'm denied. I am posting the denial letter that they sent me word for word, it is in italics. They brought up my age, 28, as a reason for denial; umm thought you couldn't discriminate based on age? I am so mad, what am I paying them $850 a month for again? I am also hoping that someone can point me to information that disproves their stance. I sent the FDA approval letter, 2 seperate letters of medical necessity and 5 different clinical trial articles.
Here is the denial:

Type of Sevice: Lumbar Artificial Intervertebral Disc
CPT: 22857
Review Outcome: Non-Certification

APPEAL
We have competed our review of the appeal you submitted for the requested service.

The service listed above has not been certified because it is considered experimental or investigational. Please refer to the plan provision entitled "Experimental" and/or "Investigational" in the subscriber's plan materials. On appeal, all clinical infomation submitted in relation to this requested service was reviewed by an independent physician board certified in Orthopedics who was not involved in the initial determination. Non-certification for the requested service is based on the following criteria and clinical rationale. Although artificial disc replacement (ADR) implants are FDA approved and recent clinical results are encouraging, the data is still preliminary. Lumbar ADR is certainly one of the most innovative and exciting developments to come along in spine surgery. It is thought that ADR can preserve motion segments in the lumbar spine, which will ultimately minimize adjacent level degenerative changes that are seen with lumbar fusion; however, the long-term benefits of ADR in preventing adjacent level disc degeneration have yet to be realized, and there is little information concerning patient outcomes and implant survivorship (Eur J Spine 2006). Moreover, complications of total disc replacement may not be known for many years, and given your young age; it is likely that you will require revision procedures in the future. While ADR is being utilized in the orthopedic spine and neurosurgical communities, further prospective, randomized controlled trials with longer-term follow-up are needed before these devices are implanted on a widespread basis.

This determination is not a recommendation for treatment. This review addresses the efficacy of the service(s) as determined by the applicable provisions of the health benefit plan. The decision regarding what treatment is best remains with the member and the healthcare provider.

Upon request, you may recive free of charge, a copy of the clinical rationale as well as any guidelines used in making this determination.

This completes the internal Appeal process.

I addressed all these things with the clinical trial information I sent. They state one source, I sent 5. It is frustrating that they can just ignore the information and cherry pick their's to base their denial on! I am not sure if I will appeal again, doubt I will get an approval. I have never heard of Unicare paying for ADR. I love how they add that the decision lies with the provider and patient.... yeah if you got lots of money to pay cash for it! I will probably just be in the Freedom Disc Clinical Trial, if and when it starts.
Kathy

[Terry Allen Blackburn]

Kathy:

This is highly disappointing. I am hoping that a new President and Congress can start getting this country back to; "We the people........." instead of; "We the corporations and shareholders......................"

Don't give up the fight yet. Maybe it is time to appeal to the State.

Terry Newton

[Justin]

Kathy,

This is complete BS. Do you happen to have the booklet for your insurance plan? I would look into the issue of age they brought up within the booklet. There should be a generic statement about persons treated under your plan.

I know it takes a lot of time and energy to appeal again, but I would--this was only the internal appeal and it is loosely put together considering they only have one reference to a study. I would request the clinical rational and guidelines they used to come to their determination. Also, investigate who came to this determination and what this person's credentials and background are (speciality, state of practice, etc.)

This is ridiculous... you need to throw study after study at them regarding subsequent revisions after the "gold standard" operation fusion.

If you need any help, let me know.
-Dr. J

[dshobbies]

Mark has a book in his library about how to appeal your insurance, etc. Ask him about it.

[sahuaro]

I cannot agree more with all the advice you have been given, especially requesting the clinical guidelines and especially swamping them with studies of the frequency of adjacent segment degeneration and need for further surgeries with fusion. This is just another example of insurance companies pulling any ploy to avoid paying but the first I've seen in which they disclaim responsibility for making a clinical decision.

On a discouraging note, I went through the entire appeal process including going through the State Insurance Department--their "independent" reviewer essentially said that because my plan specifically stated that ADR was experimental, it was not covered, i.e., he totally ignored my arguments against considering ADR experimental.

However, it is now a year later with many more insurance companies covering ADR--which may be why your company is grabbing at straws. So go for it!

[steve55]

Unicare will be tough. They are not one of the insurance co's who I h ave seen approve ADR based on my 7 months of browsing back pain boards. BUT, then again, doesnt mean they cant.

I noticed they mentioned your age requiring future revisions, but fusion is even much more likely to require further future surgeries as the adjacent discs wear out. It will be easy to counter that arguement since the theory behined ADR is to preserve motion so that further surgeries wont be necessary. Getting proof of this should be easy to find. Just google it. And the disc manufacturer should have the most accredited studies that will work in your favor. And lastly, you might show how ADR is cheaper than fusion. The initial response they are giving you is probably canned. By appealing with heavier duty stuff as I suggested , and combining that with Laurie todd's procedures (see below about her book), you should be able to force them to have to REALLY work to counter you.

Also, you might try compiling copies of peoples approvals with other carriers. Overwhelm them with it!! So much so, that they look stupid and negligent in not approving it. You can post on the various back boards for people to email you copies of their approvals for such proof. And most importantly, get a copy of Laurie Todd's book, the insurance warrior. Its only about $10 online. Google it, she supposedly tells you what it takes to make them jump. She knows how to scare them into doing it too. This book just might get you approved if you follow her advice. There are people on the boards who have gotten 2 level ADR's approved by insurance co's who typically dont approve ADR , such as United healthcare for example. Below are some posts I have copied and pasted as I was saving them for my own battle plan.

The freedom disc may not be so bad, it seems to me that people are doing well with all the various types of discs except for the early charite discs which would fall apart over some time. And being that its newer, it has a higher chance at being better than its predecessors. Just my 2 cents worth : )

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1. I'm sorry I have not been on the forum lately, but I'd be happy to share a general story on how I was able to secure approval from United Healthcare:

I initially saw a brilliant surgeon who is world renowned that did not advocate the ADR. My thoughts on why he didn't push for the surgery are simple: he's older and about to retire and he doesn't want to learn a new technique or risk tarnishing a wonderful career. There was a mix b/w doctors here in Oklahoma regarding the surgery itself. Yes, it's new, but the results have been fantastic so far. It's the nature of science and medicine to move forward while others remain skeptical. There's rarely a consensus among doctors, so don't be too worried about that. I listened to all opinions and did my own research and determined that the cervical ADR was right for me. I found a doctor who pushed me to get more conservative treatment before we considered the ADR surgery, but once that failed he said that he strongly believes in the surgery and that I was a perfect candidate (I'm 24 and otherwise very healthy). He said that if he had to have surgery, he would only have ADR surgery.


2.My approval took nearly a month and a half, so keep that in mind. In order to get approval for the surgery you must prove that its necessary and that its as good or better than the alternative (fusion). You do this with a "predetermination" (aka precertification) request to UHC. You will likely get denied at this point like most people. They only approve on a case by case basis at the highest level as far as i know. So this requires you to appeal the initial decision (it took two appeals for me). The denials will be based on the fact that they claim the ADR surgery with the Prestige Cervical Disc is "Unproven or Experimental". These terms are defined in your "Certificate of Coverage" under UHC. When you read the definitions (read everything related to them) you will see that the ADR surgery should be covered based on the language. The reason being is b/c its "proven" due to the FDA study that was completed for the Prestige Cervical Disc. This was the largest FDA study of its kind and received unanimous approval. This type of study suffices under UHC's definition of proven technology. So in your appeal letters you should submit the actual FDA study and highlight this issue. Your doctor should have the FDA study, or you can contact Medtronic for it (they make the Prestige).

3. I was mistreated, hung up on, and continually transferred during my many phone calls. I eventually filed a complaint with the OK Insurance Commission. Telling UHC I did this seemed to light a fire under their tails! My approval came within days. I attribute it to all of the factors I've listed though.



4.I am with you there!! I fought United for 6 monthes (2 disc replacement here) and finally took me taking the case to the VP of our company to get them to pay. We are a self funded group, but United LACKS much in the ways of their claim processes and denials.

I explain how to hack through the bureaucracy of customer service. People waste a lot of time on the phone when they should be putting things in writing. Insurance companies count on people making frenzied phone calls and giving up. Get every denial in writing, never accept the denial by phone. Appeal letters should be 20 + pages long with case studies supporting your claim, its intimidating and time consuming for them to have to wade through it. Make sure you send copies of each appeal to all the right people mainly the insurance co's chief medical director and title envelope and 1st page of document "urgent expedited appeal".Best weapon of all is to show how it will cost your insurance company less.

5.Insurance companies are really backasswards (yeah that's a word) in their approach to "helping" patients. I worked for a very large Health Insurance company for a couple of years. I can only tell you that those squeaky wheels seem to get taken care of... to the point where you may benefit from picking up the phone and calling the claims manager/VP every single day. jAnd yes I do mean every single day. Twice a day if necessary. I've seen this work over and over. They get so sick of dealing with you that take some kind of action. It it's an action you don't like you just keep moving up the chain - which is tough because the higher you go the more isolated they are from the General Public. Sounds like a crazy approach... but it can work.

[Kathy]

Thanks everyone,
When I posted, I was bummed and felt defeated. After reading all your replies, I feel ready to fight the fight and WIN! I know I have it in me, I'm a pretty sore loser and can definitely be the squeaky wheel (just ask my husband )
Can anyone share some clinical trials with me, that I can print? Any approval letters that I can print? Anything that would help me prove my case?

Thanks
kathy

[Kathy]

Glad to see all the familiar names and people here from the other site.

[Justin]

Hey Kathy,

I've been pretty busy lately. Just so you know...if you need any articles/publications to present for your appeal, I can get you them. I have access to almost every journal imaginable through school.

I have some pubs that I used during my appeal, which are somewhat dated now but they might help.

Let me know how I can help... we'll kick 'em where it hurts!

[mmglobal]

It's so frustrating to watch this happen over and over. It's not about fair, right and wrong, appropriateness of medical care, etc.... this is all about money.

They referred to an article that is more than 3 years old. We'll see newer data... much has been presented at the more recent conferences.

If you want to borrow the Laurie Todd's book, I'll send it to you. It's cheap enought that you might want to order it instead of having to ship it back to me. I have links on the GPN website.

All the best,

Mark

[Kathy]

Thank you Mark, I will look up the articles I have and let you know, so I can get the newer ones. I thought that it was odd that they used only one article and an old one at that. I think I will just order Laurie Todd's book, so I can get to reading and preparing to fight. Thanks again and thanks for this great site.
Kathy

[steve55]

Kathy, the Spinehealth mesage board was where I got the most replies when I asked for people to message me who have approval letters for ADR. Post the question on every board you know. But title it someting that has a call to action like" Need help-Lumbar ADR approvals, pls respond" . I would also post it in the "Insurance" sections of these back boards. And, to be sure your post doesnt sink to low on some of the boards due to last reply date sending it to the back of the line, you might reply to your own post every once in a while with a "thanks everyone" ,to bring it back to the top. Many people dont click back to far in date. In a matter of days I had 3 or 4 people who not only had their approval to send to me, but said they could share other approvals they collected for their own cases. Imagine showing them 20-30 approvals by various insurance carriers, and if you are lucky enough, maybe you will find a Unicare one that slipped thorugh their cracks. But follow Laurie todd's advice, she knows their weak spots and thats what will matter most in the end. Hey, if you got time on your hands, or dont have much else to do (due to not going out as much due to pain) this battle may give you some sense of purpose or something to work towards for the time being. You may as well give them hell since they are more than willing to give the same to you by their unwillingness to approve your ADR.

[ans]

I'm sorry to hear this. Maybe if you email Laurie she might have some inside information; she's a great person.

health insurance help

My best - ans

[treefrog]

Sorry to hear about the denial Kathy.

After reading all the advice here, I am encouraged. I had not even thought about applying to have my insurance company pay (BCBS of NC). I had just accepted that I would have to pay the $8000 (for the disc and supplies needed for that part of the surgery, since I was looking at hybrid surgery), if I chose to go that route. It would be great if I could get them to pay.

[Kathy]

Originally Posted by treefrog

Sorry to hear about the denial Kathy.

After reading all the advice here, I am encouraged. I had not even thought about applying to have my insurance company pay (BCBS of NC). I had just accepted that I would have to pay the $8000 (for the disc and supplies needed for that part of the surgery, since I was looking at hybrid surgery), if I chose to go that route. It would be great if I could get them to pay.

I am pretty sure that I have heard of BCBS paying for ADR. I think that is what Terry has that paid for his and he is in Michigan; he had surgery in Germany and got it paid for. You might pm him to make sure my information is correct.

[Roblin]

Kathy,
I'm so very sorry to hear of your denial. Stay strong and fight this thing. You are a winner! I'm sure you will get all of the ammunition you need to fight and win.
Sincerely,
Roblin

[shamsuthbegum]

I think you have more spirit so you can lead your life luxuriously.....
.............

[Maria]

In terms of adjacent level syndrome if it were fusion that were being suggested it would probably authorized and that in itself seems to have much evidence of necessity for further surgery re adjacent level problems not to mention revision surgeries.. yet because it's tried and true and been around for so long no doubt it would be authorized.

Sorry to read about the denial and hopefully it will be authorized soon. I hope you don't have to wait too long because as someone who has waited around a long time for me likey the option of ADR is out the window now because of the number of years I've waited and continued degenerative process in my spine re endplates and facets...adjacent level probs that occur anyway with no surgical intervention.

That part about being young ~ that should bode well for you in terms of recovery and that much is probably in the literature as well in terms of any surgery.

[takidenza]

In 2008 we were in a severe car accident and subsequently my wife has developed neck problems. After a Disco gram, the doctors suggested an Artificial Cervical Disc surgery. Unfortunately, everybody but our insurance (UHC) approves of this. She doesn't want to have surgery at all, but she doesn't want to have any more pain. What do I do? How do I appeal this? I feel bad for my wife and want to help her in the best way I can, and everything points to this being the best option for her. Please help us?

douglasp@mac.com

[mmglobal]

Sadly, the state of health-care in the US allows our insurance companies to deny coverage for something that has been studied and FDA approved, saying "it's experimental" - even though it's not. There is an appeal process and some have been successful, but for the intractible insurance companies, it feels like we are tilting at windmills.

Good luck... let us know how it goes.

Mark

[dshobbies]

takidenza,

Welcome to the forum. I'm sorry your wife's pain is great enough to require intervention.

Much more often than not, insurance companies are denying ADR coverage with only a few successful appeals. Most of us who had this surgery had to pay on our own and many of us went to Germany for the best surgeons- Drs Bertagnoli and Zeegers. The cost is half the price vs the cash price here in the US. I sometimes wonder if doctors and hospitals realize how much business they're losing to other parts of the world?

Anyway, please start a new post and tell us her story - or have her tell it herself. We're here to help.

Dale