New to the board

[RedStang]

Hello all!! I recognize some names from another board but I'll give my background for everyone else.

I began having headaches that started in my neck back in 1997. They were severe enough that the Navy medically discharged me in 1999 with a diagnosis of tension headaches. Truthfully many of my shipmates thought i was full of sh** and just trying to get out. Thankfully the ones I worked with back in the engine room could see the pain I was in and never questioned me.

I suffered through the headaches for several years before I started developing pain in my wrists. My GP and I both thought that it was the beginning of carpal tunnel. A year or two later my left wrist began to hurt. Throughout this time I would have brief shots of pain in my shoulders and arms. I honestly thought I was imagining the pain and never disclosed it.

Finally in Jan 2007 I experienced excruciating pain in my arms, wrists, and hands when finishing my basement. I hate frigging drywall. Anyway, my GP sent me too a ortho to check for carpal tunnel. The guy spent about 30 min's with and sent me to a spine specialist.

The x-rays immediately showed thinning at C5/6 and an MRI confirmed advanced DDD. This was June 2007. The day before a follow-up with the spine ortho the prestige disc was approved by the FDA. My doc and I excitedly discussed the possibility of going with ADR over fusion. In September 2007 after PT made my pain worse I submitted a precert for ADR.

It was quickly denied and when I inquired with my employer if there was anything they could do to help me as we were self insured I was told that they could not as to make an exception for me meant they'd have to make an exception for anyone. This was October 2007 and I was regularly putting in 60-80 hour works weeks, salaried, as we were implementing an ERP package in a 24/7 manufacturing environment.

In December 2007 I accepted a new job with a new company in the hopes of getting more favorable insurance coverage. In June 2008 I got a referral to one of the best ortho spine surgeons in the southeast by a friend who is also a doc at Emory. Mainly I wanted a 2nd opinion. This doc was much more hesitant to recommend ADR. I discovered later that this was because he was involved in the development of a particular ADR and did not want to seem biased or have a conflict of interest.

Finally in December of 2008 we submitted a precert for the Prestige ADR with the hope that the Bryan disc would be approved shortly. It was denied, and denied, and denied again. At this point I engaged my new employer, making sure to point out the reduced recovery time and encouraging promise on reducing adjacent DDD since motion is maintained. The same info I gave my previous employer. My new employer is self insured also.

In short time my HR VP was asking our Aetna rep why it kept getting denied as experimental when it was FDA approved. Aetna denied the procedure again saying that the screening company, ActiveHealth, had correctly researched my issue and explained their decision.

At this point I found an Aetna policy bulletin that explicitly stated that ADR's were supported. My HR VP again demanded from Aetna how their policy could be so clear yet I be denied coverage. She was told that my case was being sent to a review board to ensure that ActiveHealth was making decisions in accordance with Aetna's policies.

3 long weeks later on the same day I let my VP know that I had sent my info to Stenum for review she emailed me back and said she was on the phone with Aetna and the denial had finally been reversed.

To make the day even better I've been told that the Bryan disc will receive FDA approval very, very soon. So I called my Dr and we'll schedule a surgery date probably in late July to give the Bryan disc a chance to get on the street and then have Aetna approve the change in device.

Sorry for the long post but I hope that it encourages some people who have initially been denied to keep fighting. I even changed companies in an effort to get more favorable coverage and it paid off for me.

Thanks,

Jason

[steve55]

Its so sad that insurance companies are saying "NO" to procedures they either already state that they do cover or that should be covered. Its all about money. Really sad and unethical and immoral indeed. They only give in when you appeal and put up a fight, which most people dont , most people just give up.

Im appealing for a 3 level ADR reimbursement with Aetna and Im going ALL THE WAY BABY!! Whether I win or lose, Im given them hell. IN fact, Ill spend another $3k to $5K to take them to court in the end if necesssary. Maybe Ill lose still. WHo cares, Im give em hell either way. SO far, I do have at least 1 case of prescedencse where they have paid for multi level ADR. Im looking for more but every time I find people on these boards who have had aetna cover their multi level ADR, they say they've thrown it away already. OH well.

[RedStang]

Originally Posted by steve55

Its so sad that insurance companies are saying "NO" to procedures they either already state that they do cover or that should be covered. Its all about money. Really sad and unethical and immoral indeed. They only give in when you appeal and put up a fight, which most people dont , most people just give up.

Im appealing for a 3 level ADR reimbursement with Aetna and Im going ALL THE WAY BABY!! Whether I win or lose, Im given them hell. IN fact, Ill spend another $3k to $5K to take them to court in the end if necesssary. Maybe Ill lose still. WHo cares, Im give em hell either way. SO far, I do have at least 1 case of prescedencse where they have paid for multi level ADR. Im looking for more but every time I find people on these boards who have had aetna cover their multi level ADR, they say they've thrown it away already. OH well.

Thrown it away? Oh heck no. I'd be holding on to that for a while.

[Justin]

Originally Posted by RedStang

Thrown it away? Oh heck no. I'd be holding on to that for a while.

No joke! That thing would be framed. Good luck Jason...hopefully, things will get much better for you in the coming months. Keep us posted!

[dshobbies]

Without actually tallying the total, I'd say 95-99% were turned down by insurance. You stuck to your guns and got it approved. Good for you. When is your surgery scheduled?

I wish you good luck, Dale

[RedStang]

Originally Posted by dshobbies

Without actually tallying the total, I'd say 95-99% were turned down by insurance. You stuck to your guns and got it approved. Good for you. When is your surgery scheduled?

I wish you good luck, Dale

Thanks! No date yet. We're waiting for the Bryan disc to be approved, which should be very shortly, and then schedule it out far enough to give us time to fight round 2 with Aetna.

[Terry Allen Blackburn]

Good for you for sticking up for yourself. It sounds like you may win the battle. I wish you luck in the continuing fight and hope that this goes well for you. Please keep us informed. Many here have not been so lucky and it's refreshing to hear some success stories in battling the insurance gods.

Terry Newton

[Kathy]

Welcome and good job on fighting the insurance. I tried and gave up. My last denial said that due to my age that there was no guarantee on how long the disc would last. I got in a clincal trial, had surgery and am in recovery. You will soon be on the other side too, best wishes, Kathy

[RedStang]

My surgery is finally scheduled for August 5! My wife and I go to Kauai for our 10th, come back on July 23. Pre-op appts July 28. I will be getting the Bryan disc. this all assumes that insurance doesn't throw a fit over the change of devices. Time will tell.

[treefrog]

Great news! Good luck on getting insurance to approve the change in device.

And have a very nice anniversary in Hawaii.

[Maria]

Hi Jason,
Have a great vacation and best wishes with surgery! please let us know how it goes and if the h/a's go away as I've had a huge increase in neck pain/headaches (migraines) and I do have disc bulge at C 5/6 albeit small and the OSS I see is unconcerned (last MRI done Nov.2008).

Hope all goes great for you with upcoming surgery and recovery

[Eddie G]

The insurance industry is set up to say no and wear you down while you are fighting them. They have the upper hand because while their employees are just doing their job in saying no, we the patients are gettlng stressed out and broke and emotional. They count on that. They also count on the patient to give up because many do. I'm not sure of the actual % that give up, but I'm sure the insurance industry does.
I have had my own personal struggle with the insurance companies. I got everything I wanted by NEVER giving up and played the game by their rules.

I actually have a case pending:

I went to a foot doctor because of foot pain. I was diagnosed with plantar fasciitis. I was given PT, a cortizone injection, and a prescription for orthodics to wear in my shoes. I needed to get prior authorization from Aetna for the orthodics which we got. I paid the co-pay, the orthodics were molded and in a few weeks I had them and used them everyday. We e e elllllll......
I get a letter a few weeks later saying that Aetna is really not paying for the orthodics because it is experimental and should not be one of the first treatments given for plantar fasciitis. This is after they had already approved it. So my foot doctor is appealing and was actually denied first appeal. We are on the second appeal with the doctor's office. If we happen to lose third appeal I can begin a lawsuit on my own since I would not have gotten the orthodics had they not been approved in the first place.
I think that someone initially approved the orthodics, then at the end of the month when the bean counters did their budget some red flags went up and they reversed those prior auths. like they never happened. Well I have all the papers approving the orthodics and that's what I went by so I trust Judge Judy to be fair & honest when I bring Aetna into her court for a couple hundred of dollars and alot of principle. Luckily I can spend time in court as long as I have a place to lay down.
I would also go to Judge Mathis. He's cool man!
So this is typical for insurance companies. I've gotten used to all this crap in the past 6 years. It's hard to keep a cool head when dealing with insurance people but try. It's frustrating having to micromanage your life surrounded by incompetants, but if you don't micromanage your life, nobody else is going to do it for you unless you're a multi-millionaire and can afford a personal micromanager.

Maybe Mark can add personal micromanaging to his list of patient advocate duties? I think Mark is way too nice to yell at the insurance companies the way they need to be yelled at. Maybe a gangsta rapper would be a good person to deal with them, better yet, state prisoners and we can pay them in cigarettes.


Or we can outsource to India...

[RedStang]

Originally Posted by Maria

Hi Jason,
Have a great vacation and best wishes with surgery! please let us know how it goes and if the h/a's go away as I've had a huge increase in neck pain/headaches (migraines) and I do have disc bulge at C 5/6 albeit small and the OSS I see is unconcerned (last MRI done Nov.2008).

Hope all goes great for you with upcoming surgery and recovery

Thanks and I'll definitely post in the surgical outcomes forum. I haven't across too many people that have the h/a's but I am hopeful that they'll be resolved as my surgeon seems confident that they are related to my DDD.

[dshobbies]

Jason,

Ten years is a long time and a great milestone. Have a great time on your anniversary and may you celebrate your 50th together too

I agree with Eddie when it comes to insurance companies except for the anger part. As someone with a redhead's temper, I've learned the hard way what my mother told me all my life - you catch more flies with honey than with vinegar. I think you might have a battle with a change in device. But then again, you never know.

Regardless, good luck with your surgery and please keep us posted.

My best to you, Dale

[cavalier]

Really ? on the H/A's i have them all of the time no med's can touch them. Mine start usually at the back of my neck like someone whapped me with a baseball bat on the back of my neck when I wake up & sort of srpead forward. Those have been unrelenting since last July sometimes i can get lucky & have a day off here & there. Good luck & have a great safe anniv. Trip.

I also need at least 2 levels C5/6 C6/7 poss. a 3rd C4/5 TBD by a discogram. Dont have 53k or more for 3 levels & cant keep waiting. like you started with left hand wrist kept thinking it was my hand as i had torn that ligament & broke it once - a few years before that was hoping not the neck from a MVA yr's before but knew after that MVA neck was not great. Now it's both arms. I hope you get this covered. i have ruled out arteries and done all sorts of tests as they found abnormalities in the arms blamed it on my extra Cervical Rib but I now have proven that is not the source - duh the abnormal MRI with herinated at one level & prolapsed disc with 7,8, & 9 mms for the foramen normal is 15 to 20 mm's under 10 is cord comrpession - duh - so I am going to send my tests to the 1 spine doc who said pull out the cervical rib. The other 2 SS doc's saying ADR fix the neck are correct. At any rate I am in the SE - who is going to work on you ?
Best wishes & let us know how you come along - Jill

[RedStang]

Originally Posted by cavalier

Really ? on the H/A's i have them all of the time no med's can touch them. Mine start usually at the back of my neck like someone whapped me with a baseball bat on the back of my neck when I wake up & sort of srpead forward. Those have been unrelenting since last July sometimes i can get lucky & have a day off here & there. Good luck & have a great safe anniv. Trip.

I also need at least 2 levels C5/6 C6/7 poss. a 3rd C4/5 TBD by a discogram. Dont have 53k or more for 3 levels & cant keep waiting. like you started with left hand wrist kept thinking it was my hand as i had torn that ligament & broke it once - a few years before that was hoping not the neck from a MVA yr's before but knew after that MVA neck was not great. Now it's both arms. I hope you get this covered. i have ruled out arteries and done all sorts of tests as they found abnormalities in the arms blamed it on my extra Cervical Rib but I now have proven that is not the source - duh the abnormal MRI with herinated at one level & prolapsed disc with 7,8, & 9 mms for the foramen normal is 15 to 20 mm's under 10 is cord comrpession - duh - so I am going to send my tests to the 1 spine doc who said pull out the cervical rib. The other 2 SS doc's saying ADR fix the neck are correct. At any rate I am in the SE - who is going to work on you ?
Best wishes & let us know how you come along - Jill

My HA's tend to start the same way. For ten years HA's were my primary pain generator but over the last 2 years my arms have taken over. I had same symptoms though where every once in a while I might go a couple days without the pain.

I'm being seen by Dr. Heller at the Emory Spine clinic in Atlanta.

As far as insurance coverage I had actually called this morning to check on the change in device and was told that Aetna's codes are for the procedure, not the device. I'll definitely be asking for clarification on the 28th during my pre-op appt. They understand that it's the Bryan disc for me as we've rescheduled the surgery twice waiting on insurance approval for the procedure and FDA approval for the Bryan disc.

Thanks for the well wishes!

[RedStang]

Had my pre-op appointments yesterday and I will be getting the Bryan disc. 1 week to go!

[dshobbies]

RS,

So far, so good. With one week to go you're probably feeling so many emotions you can't even describe them. Focus on the day after surgery and you'll do great. I look forward to your post-op posts telling us how great you're doing,

Good luck, Dale

[mmglobal]

RS, I'm looking forward to hearing great news! Please keep us posted. All the best,

Mark