Insurance won't cover lumbar fusion

jerryjezza · #1 (**permalink**) 02-19-2011, 08:05 AM

I know about this pain because my uncle had this pain.
My opinion is that in general, insurance companies have it right regarding lumbar fusion surgery, but they are inconsistent in their policy regarding lumbar fusion surgery for disc related low back pain. They acknowledge the diagnosis exists by allowing artificial disc replacement, but for some reason they do not believe that lumbar fusion is a legitimate option for the same diagnosis.
It would make sense to stick with a tried and true treatment like anterior lumbar fusion for one-level disc related chronic low back pain, and approve new technology such as artificial disc replacement only after it is shown to be superior, not just equal.

karreymetris · #2 (**permalink**) 07-05-2012, 05:28 PM

Are insurance companies really this difficult? I have never even used mine for anything, never been hurting enough until now.

mmglobal · #3 (**permalink**) 07-05-2012, 06:41 PM

Kerry, it is insane. For the first 9 years I did this, we were frustrated because the insurance company would not pay for ADR. Few have been successful... many more for one level procedures, very few for more common multi-level cases. Cervical ADR was adopted quicker, but many companies will not pay for anything if the term ADR is anywhere nearby... even for hybrid surgeries that are one level fusion w/one level ADR.

Lately, they are even more emboldened and are denying more traditional surgeries like fusion.

As long as the politicians continue to write laws beneficial to industry, even when the industry is completely unreasonable (eg: when they literally deny everything and make the doctor's offices go through a very laborious and paper-intensive process, just for ordinary treatments!), we will be powerless to fight the nonsense. Actually some will fight and win... many, many more will fight and lose; and most won't be able to fight the system. How sad. IMHO, anyone who thinks that the status quo for our medical system is acceptable and reasonable is not well informed about the egregious abuses of the industry.

Having worked for over a thousand spine patients now, I have seen many lives ruined because they don't have insurance, or they have insurance and they deny needed treatments (that all the patient's doctors see as appropriate) and because the patient gets FORCED to accept the wrong treatment because their insurance won't pay for the more appropriate treatment.

We are not talking about wacko experimental procedures. We are talking about something that was FDA approved in 2004!!! They still are allowed to say, 'it's experimental.' That is just BS.

End of rant.

Mark

Roz · #4 (**permalink**) 04-05-2013, 01:26 AM

Hi,

I agree with your comments. Maybe someone out there would help me with a question I am concerned over. I had a one level ADR implanted in Bangkok, Thailand in 2005 at Bumrungrad Hospital. Dr Nanthandej never told me he had no idea how to implant this device ( Pro Disc C C5-6). The implant was placed under sized and is too far ventral and subsiding according to Dr. B in Germany. I sent films to Dr. Demakas in Spokane who was trained I believe by Dr. Ritter- Lang and he agreed. it is auto fused and it has to be removed. I do not want a fusion.

I am now being told that a revision arthroplasty, even with another Pro Disc is not covered. Does anyone know the truth about this.?

mmglobal · #5 (**permalink**) 04-10-2013, 05:25 AM

Roz, a single level fusion is a good surgery with good results. While that is not what we want when we go for ADR, considering the cervical revision and fusion (especially at one level) is so much easier to entertain than lumbar revisions or fusions.

Good luck!

Mark

jsewell · #6 (**permalink**) 06-17-2013, 02:56 AM

I now have a lawyer who works with a foundation sending in an appeal for me for the growth hormone i have been denied for a year. As an adult the growth hormone helps with bone hardening. As a child we all know it provides growth up. I have had so many spinal fractures, do not have osteoperosis and can only point to this hormone , which i am very deficient in. Yet Aetna can't see the big picture.
It was submitted last week, so now they will take their sweet time. The next step is with the state and an independent doctor.
Judy