Help with approval ltrs and finding studies for my appeal

[steve55]

Again, as I already posted last week, anyone who has a multi level approval letter (cervical or ADR) to share with me, please do.

At this time, Im completely stonewalled/stuck on how to find the following

1. Studies that show multi level ADR as good or better than fusion
2. Studies showing ADR cheaper than fusion, preferrably multi level
3. Peer reviewed articles publsihed by my dr, dr bertagnoli and Aetna's in network doctor Jack Ziglar (since he alsdo reccomended 2 level ADR for me). Im still not quite sure what peer reviewed is, how you know when a article is "peer reviewed" and how to find them. Im so freakin lost on that, Ive googled all I can with no results.

Anyone who has already done the appeal fight, Id love to have all your literature/science articles that you used, assuming you saved them.

Thanks

nees2000@sbcglobal.net
Fax 972-267-7977

[Katie]

We're both fighting the same fight, Steve. The information I've found applies to Canada, Ontario specifically, as that is my battle, but it may give you something to work with.

In April 2006, the Ontario Medical Advisory Secretariat for the Ministry of Health and Long-Term care put out a 96 page Policy Assessment regarding Artificial Discs for Lumbar and Cervical DD Disease-Update. (Whew!)
You can find it online.

On page 54 of that report, the government found that the median hospital cost of a lumbar fusion surgery procedure was estimated at $8,774. The average cost for a lumbar artificial disc replacement procedure was $5,971.

The professional costs on top of that (for anesthetist and assistant costs, etc.) for the fusion was $2,636.56, while the lumbar ADR procedure cost $2,537.37. Not such a difference as far as the doctors' fees, etc. go, but the hospital costs were significantly different.

It took quite awhile to find a breakdown of hospital costs. I found the Schedule of Benefits for the physicians easily online.

I am sure I have come across many publications stating that ADR is better than fusion, but not sure if I have any regarding multi-level, which is what I have to prove too. Unfortunately, the company reps have told me that multi-level have not been recommended at their end, that it is at the doctors' discretion.

I'll do some more digging to see if I can help at all.

All the best with your battle.

[dshobbies]

Steve,

When searching for my own appeal, I discovered that a 3 level fusion is actually contra-indicated. Don't know if that applies to a 2 level also and can't tell you where I found it but it's worth some research.

BTW, I ultimately gave up, mainly because I decided Dr. B was best for me and there was no way BC would pay for surgery in Germany.

Good luck, Dale

[sahuaro]

Dale:
Do you remember any details about why 3-level fusion is contraindicated?
Does that apply to both cervical and lumbar?

A friend of ours just had 3-level cervical ADR and is planning to appeal, as well. His "choice" for surgery was 4-level fusion or 3-level ADR.

[trkdoc714]

Steve,

You may want to get an "estimate" from Dr. Ziglar and any other ortho/ neurosurgeon that will give a cost estimate for multi-level fusion and use that as a comparison.

You may want to offer signing an agreement to not file a claim for revision surgery if needed. I think I've read that your surgeon performs revisions (if needed) as no charge "warranty" except for travel expenses.

I haven't gotten there yet, but maybe a workers comp attorney can help you navigate your way through these processes.

It's important to not let yourself get discouraged at the rejections, just keep hammering them on a monthly basis.

Good luck,

Bob

[dshobbies]

Sahuaro,

If memory serves, I found this article almost 3 1/2 years ago, it pertained to lumbar fusion and the reason for the contraindication was multi-level fusion actually promoted DDD.

I searched my bookmarks in an old computer (shocked I still have it), I googled it and looked for the article which I printed out but so far, nothing. I will soon be putting my 2008 records into storage and will see if I can find the article in a storage box but keep in mind, if this was written 2004/5, it may no longer be relevent. However, I suspect it is.

While looking through my bookmarks, I'm pretty sure I found the article in Back Pain: Trusted Information for Pain Relief | Spine-Health. Sorry I can't remember more.

Dale

[chasswen]

heres a great site for papers written by doctors just search link is for bertagnoli.
Bertagnoli,R
chuck

[steve55]

Thanks to all who replied. It's a starting point.

[treefrog]

I knew there was a paper that I had seen in the articles section of this forum, that compares cost of fusion with ADR. It is for single level, but I would think it would transfer to multi-level. At least it is a starting place.

Here is the thread.

http://www.ispine.org/forum/abstract...us-fusion.html

But let me know if you can't pull up the paper. I can save it in PDF, and email it to you, if need be.

[Katie]

treefrog, that is a very good article. Is there any that give actual cost in dollars and cents? I know that is hard, with the costs being scattered between the hospital departments, etc. It took a long time to find that for up here.

The ironic part is that the report also states, along with almost every other publication I've found, that the reason they are not doing more ADRs is because of costs....even though their other own government department proves that it is instead cheaper, not more expensive. I suspect they mean that they can not afford all the training, etc. Short sightedness again.....

Have you had any more luck with this, Steve?

[steve55]

Yes, The best tool is using pubmed. The people at spine journal said the pubmed website pulls of all their studies as well as others, and its free. It just pulls of a basic overview with the conclusion of the stufy. Heck, thats perfect for me as I will highlite the conclusions to prove my points.

Havent been able to find any articles comparing the costs but am having my Dr ziglar folks work up a estimate with codes for what a 3 level fusion would have cost (incl hospital bill estimate).

The insurance warriror talks about pulling up 100 peer reviewed studies but there just arent that many out there so Ill end up submitting around 25 to 30 I think. Sure wish I had more Aetna approval letters as this is the biggest weapon at getting approvals.

I plan to take them to court if necessary as long as the atty is willing to take me on with a $$ cap. I can maybe pay $2-$3K fee and also be willing to fork over a portion of the reimbursement or something to get a attorney to help me. One way or another, Ill fight like hell to the bitter end and be a thorn in their side just for the sake of PRINCIPAL. Ive paid my insurance dues and I deserve to be reimbursed for a service Ive paid for all these years.

Im following Laurie Todd's advice to a tee and Ill call her or email her if if necessary to get the Aetna insider ph and fax# if necessary. Im a bulldog when it comes to matters of injustice. Ive fullfilled my end of the contract/obligation by paying their dues all these years and now I expect them to fulfill theirs.

[Terry Allen Blackburn]

Good for you Steve. I hope everything works out for you.

Terry Newton

[chasswen]

sorry to say this but it's true. one can't sue a non-for profit insurance company for any more then the act costs of the surgery. no travel or lawyer fees etc...
been there done that with blue crap.
chuck