ADR/Fusion Combo

[ans]

Saw Dr. Regan today and he told me that his suggested fusion/ADR combo can be denied in toto by insurance companies. Why? B/c some consider this hybrid to be "off-label" use.

Geeze, I thought the fusion part would be covered as it's standard.

ans

[chasswen]

ans
you wont know untill you submit to the insurance company
some are paying are the fusion part.
chuck
ps long time no see

[dshobbies]

I too was supposed to have a fusion/adr combo by Dr. Regan. After bc denied coverage, I offered a variety of compromises including paying for the surgical costs of the adr if they would cover everything else, but they wouldn't budge. It doesn't made sense nor is it fair, but they hold all the cards unless you're willing to go the legal route. Even that solution isn't definitive but an offer of compromise goes far in the legal world.

Good luck, Dale

[mmglobal]

I'm seeing this paid for and also denied. I think that it's very bad and getting worse... what's happening with the insurance companies. They are emboldened to let bean counters countermand the doctors and the FDA. They get are denying lifesaving treatment to people who have no alternative. This is about money and has nothing to do with appropriateness of care.

We used to think that we'd get medical insurance and it would be there when we need it. Now, they are canceling policies because people need it. This is bad and getting worse.

Mark

[ans]

Thanks for your quick replies/help. Yes, it's weird.

Congrats. on this new forum Mark (and Poncho).

Allan

[nopain]

Isn't it great we live in a country with so much technology and we can't even use it! Is it cheaper to let patients suffer for years an years and pay for continual treatment and more surgery down the line or to offer a solution to the problem and fix it?

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.

If you have to take a legal route and you can afford to do so - do it! Not until the insured start standing up for better medical care will the system change. To the insurance company you are nothing more than a number. You need to put your face in front of these people. There needs to be media attention to these cases.

Are the Germans so far ahead of us technologically? Perhaps? Perhaps not, but they certainly do seem to care about their citizens a whole lot more.

[Maria]

What amazes me is that a global 3 level lumbar fusion was authorized for me by WC (before reform here in CA/2005) as well as the 2 level ADR but the hybrid surgery with ADR at L4 and fusion at L5S1 was denied and the reasons for denying the fusion were absolutely ABSURD... I mean, you wouldn't believe the crock of crap that was on this lengthy UR denial...

Currently my Nurse Case Manager says she can't even talk with the Claims Adjustor as she gets absolutely no reply unless it's by email and then it's a very limited response so even she is practically out of the loop.

All the bull WC is going thru to deny surgical requests for me is probably costing at least half of what the surgery would have.. it's ridiculous~

WC Reform and cost containment my a**~

BTW, got off subject a bit tho good luck Allan if this is what you want or would proceed with. Myself I think that the $$ spent to go to Europe and have surgery would be well worth it if I had it~ vs. Insurance companies dictating what medical care should be vs. specialists in the field of medicine/surgery and other~

[ans]

Yeah Maria, the ideal is to see Dr. B. or Z. Alas, I won't have the up-front cash until 3/4 a yr. from now; all I can do is wait or keep hammering insurance in pre-appeals. I don't know how the latter works 'tho..

I certainly would feel weird having surgery as my symptoms are not debilitating as yours sometimes are (not being able to sit, etc.).

Wishing you and everyone here well. - Allan

[Maria]

ans
Ran into my Nurse Case Manager went I went to a Neurology appt. for migraines in this medical community in San Diego (Hillcrest area) and I was one day post ESI this past week~ I was doing SO GOOD ~ as I usually do after the ESIs and she advised that if they work that well for me, I try to get as many as my PM will order/yr since the WC machine is moving REAL slow it appears w/any surgical request on the table...

I'm happy w/this amount of relief, and can sit to some degree for short periods of time but the cummulative effect of that and being active can really escalate into some kind of high level pain~ thankfully at present relieved by rest. Crash and burn~ I do this so well...

Yeah, I'd not really want to submit my bod to surgery either if symptoms didn't really knock me off my feet or I wasn't in danger of a rapidly deteriorating neuro prob or other. Seems like you can probably wait and take care of things at a later date?