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