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.