BC/BS Coverage Of Disc Replacement

mudlakeslim · #1 (**permalink**) 02-20-2007, 05:51 PM

Since BC/BS of Michigan currently does not provide coverage for the artificial disc replacement procedure I will begrundgingly schedule for the fusion surgery in April of this year. Both my doctor and I agree that the disc replacement is the preferred method of treatment but since I am not able to pay for the surgery myself and BC/BS consider it experimental and investigational I will go with the fusion.

If anybody has any information regarding talks between BC/BS and the makers of the artificial disc I would like to know about it so I can inform my physician. I realize that the time frame is not looking too good for me as far as an overturning of their current decision on this matter but it could help other patients who are just finding out that this surgury is not covered by all policies.

dshobbies · #2 (**permalink**) 02-20-2007, 06:19 PM

We've been around the block with insurance companies so many times we now view them as the 'enemy', for they stand between us and our options for what is deemed the best or better medically sound treatment(s). I was told by my pm that treatments are considered experiemental/inv. for about 5 years after FDA approval but I assume there must be exemptions.

All that being said, yes, there have been those that were fortunate enough and have fought enough to get coverage, though few and far between. Charite even provides a kit with instructions for insurance appeals. But, if you have little time, you may be out of luck.

I would suggest appealing with a request for a peer to peer consultation with your doctor. The insurance company must then provide an equivalent physician, whose speciality matches that of your doctor and who is knowledgable in ADRs. At least your physician will be able to provide details that make an ADR a better treatment for you and will be speaking to someone who is not and ENT or internest, etc. Then again, I gave up and went to Germany but that was going to be my next appeal had I continued to fight.

Paulette did win a limited appeal and provided me with excellent questions. If your time is limited, you may only have time for one appeal so you'll want to get everything in there. Paulette, are you there??????

I wish you every good luck, Dale

mmglobal · #3 (**permalink**) 02-20-2007, 06:36 PM

I was speaking to Rick Delamarter earlier this month. At the end of February, he is addressing a meeting with BC/BS explaining all the ProDisc data and basically pitching ProDisc again. As I've seen in the 2+ years since Charite' approval and the fiasco with insurance reimbursement and acceptance of the device, the folks at Synthes have learned well the lessons taught by J&J's Charite' experience. Armed with this knowledge, they will do a much better job and I hope that they will be able to bridge the gap between what the surgeons know as an improvement in the standard of care and what the insurers see as a big risk and more money out of their pocket.

I wish I could say that I thought the insurers were trying to protect us, but I firmly believe that this is just about money. Hopefully an overwhelming case will force the pencil pushers to yield to the doctors and the data. Unfortunately, media hype, pressure from competitors, lawyers taking advantage of new technologies (as in the Charite' lawsuits), and some doctors who see the value in being the leader of the ADR naysayers (Rosen, Van Ooij) will provide political cover for the insurers to save themselves money and delay approval of reimbursement.

Hopefully, Dr. Delamarter will knock their socks off next week. Hopefully, the insurers will put patient welfare and appropriateness of medical care first. As with FDA approval, I'm not holding my breath. The insurance landscape will change in the years to come. Will it be soone enough for you? I hope so.

Mark

PS... I'll try to get more details about the meeting...

sahuaro · #4 (**permalink**) 02-21-2007, 02:29 AM

Arizona BC/BS lists both lumbar arthroplasty and removal of arthroplasty as procedures in its fee schedule. Because removal is listed, I have been assuming that "arthroplasty" includes ADR. You may want to check this out.

Poncho · #5 (**permalink**) 02-21-2007, 08:17 AM

I would love to be a fly on the wall of that meeting Mark! The whole presentation and how Dr. D will defend it. I know that I would definitely come away from the presentation learning a lot of new things.

Yep, it is all about money. The "bottom line" question they will try to answer is do the risks outweigh the benefits???

Insurance and finances are such a major barrier to access health care services. I would love to hear Dr. D's speech on this as it relates to a patient's "utilization of services", costs compared to fusion et al, and as with any insurance company - risks associated and patient outcomes. Especially since it seems that Medicare, Medicaid, and Managed Care are heavily looking at performance measures / patient outcomes as part of their reimbursement methods......- From what I understand.....

Please keep us posted.

Maria · #6 (**permalink**) 02-21-2007, 05:29 PM

I'd love to hear Dr.D speak as well with regard to ADR option and coverage by insurance companies. If it could only be salvage of the greater number of spines for the best possible outcome vs. tried and true and seemingly multi surgeries as a result w/fusion.

Mark, please share if you've a chance whatever you might learn about Dr.D and insurance companies face off. It should be good~

It would be great if insurance carriers thought it awesome they could save significant $$ for patients going abroad let alone patients having ADR here in the states.

As you stated Mark, insurance landscape will be changing over the years and will it be soon enough ....??? Hopefully for the younger spineys tho keeping fingers crossed re the oldies like myself..

Poncho · #7 (**permalink**) 02-21-2007, 06:58 PM

Hey Maria,

Have a look at this link:

http://www.workforce.com/section/02/.../80/index.html

It is about companies looking at sending their employees abroad for health care with possible savings - etc. Of course companies are hesitant still - but they are giving it a good look.

This is just Poncho's 2 cents - but I think that with the inflationary costs of health care, having patients go abroad will definitely introduce competition and may just help improve things over here. Of course there are regulation issues, however, this may be on viable option as many industries are going global.

TTYL,
Poncho

mudlakeslim · #8 (**permalink**) 02-23-2007, 04:33 AM

I found a few things on the interernet that indicate that BC/BS has denied coverage of ADR because of a poor track record of success with the Charite product. This is some cause for concern since until now I was under the impression that the lack of case data and overall costs were deterents in coverage of this procedure.

One article I read said that removal of a faulty artificial disc was difficult and life threatening. Some studies showed that persistant pain was still an issue with many ADR patients.

Since informing my doctor about the meeting in California regarding ADR they are hoping there will be a turnover in the decision and that having the disc replacement may still be an option for me. I did read another article where BC/BS of Oklahoma was adding ADR to their patients coverage. Here is a link to that information:
http://mcgs.bcbsfl.com/index.cfm?fus...tebral%20Discs

Here is another site which is of the lawsuit variety but still has a somewhat negative view of the Charite ADR procedure:
http://www.lawyersandsettlements.com...e-victims.html

Here I have been fighting for BC/BS approval and now I am finding these negative views on the surgery I was so sure was preferred over the fusion surgery. I understand that there are multiple motivations for people to be for or against this, depending on whether you are a surgeon, a patient or an insurance provider. It's a lot of information and opion to sift through and the rest of my life depends on the decision I inevitably make.

Poncho · #9 (**permalink**) 02-23-2007, 05:37 AM

Mark,

Boy, these posters make some good points here. When I was looking at trying to get ADR stateside - Anthem BCBS was my 3rd party payor source. And yes - they denied everything. Actually, as a case manager in the hospital - I have found that they will try to deny everything and anything.

BCBS - no matter which state they are out of needs to benchmark their data with the European experience and those patients that have been through the clinical trials et al. Regardless if they like it or not - their actuaries are going to realize that this IS going to be a "standard of care"!!!

mudlakeslim · #10 (**permalink**) 02-23-2007, 10:56 AM

I wonder how long it will take to cut through the BS associated with the business aspect of this whole thing. Those of us who are patients need to have access to the best care. It seems like the static between insurance companies and ADR manufacturers is getting in the way of that. Regardless of the negative findings out there with ADR it still seems like the logical choice after weighing it all out. I wonder about the manufacturers of the cages, what role are they playing in negative reviews of ADR?

dshobbies · #11 (**permalink**) 02-25-2007, 04:36 AM

Though I did not include it in my appeal to BC, I've since discovered that fusion was actually contra-indicated in my then 4 level procedure. Had I continued with that course of action, I wonder how they still would have explained their denial, though have no doubt they would have found a way.

Insurance companies wear us down, mostly because we're in pain and just can't take it anymore! It's time to turn the tides.

My feelings aside, you go Dr. D.

mudlakeslim · #12 (**permalink**) 02-26-2007, 07:05 PM

Any results from the meeting between BC/BS and the ADR people?

annapurna · #13 (**permalink**) 02-26-2007, 07:55 PM

Something to remember when dealing with insurance companies: they are in the business of making money, NOT helping people. Insurance companies want to collect the maximum amount of premiums while paying the least amount for patient care...period. If they don't, they go broke.

One way to do that is to deny every single procedure they can for whatever reason they can. While this does not always make sense in individual cases such as a $50,000 ADR vs. a $100,000 fusion, limiting access to new technology probably makes the insurance companies more money in the long run.

It's too bad that these profiteering companies essentially run the health care system in this nation.

mudlakeslim · #14 (**permalink**) 02-26-2007, 08:09 PM

The system could work splendidly if not for greed.

annapurna · #15 (**permalink**) 02-27-2007, 02:19 PM

So true Mudlakeslim! All of us just want to have our pain reduced as much as possible and be functioning, contributing members of society. No one here is looking for a free ride.

If the folks running the health insurance companies dropped their greed as you suggest, the system would probably work great.

dshobbies · #16 (**permalink**) 02-27-2007, 09:35 PM

As I just posted, nothing will end until theie business practices are challenged and I believe this will only be accomplished through the legal system. Customer service pretends to be on our side but then a letter arrives that appeal after appeal has been denied because of.....

We feel our hands are tied because to challenge their claims, we must have proof through documentation which does not as yet exist. However, denying claims in the 11th hour is negligent and possibly a cause of action.

I don't know if this falls under malpractice but with so many of us, perhaps a class action will open their eyes.

Am I sue happy, perhaps... I'm very highly principled and believe strongly that we deserve to be treated with dignity. We were wronged. Greed won't stop without a good reason.

Dale