BC/BS Coverage Of Disc Replacement

[mudlakeslim]

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]

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]

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]

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]

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]

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..