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Aetna denial for two level disc replacement and will only approve fusion

Hi all I’m new here. Yes I have a big problem.Early October I had a fall that whiplashed my neck. I really did not think it did anything. A few days later my daughters boyfriend and I were putting a gun safe in our basement. We were using a moving dolly. While lowering it down the stairs I felt a pull in my shoulder and neck. Dam that hurt. Later it was aching so I iced it . Days after it was getting worse. As soon a I dropped my arm pain radiated down it along with pins and needle sensation. To get to the real deal of this story. I was diagnosed with two significant herniated disc at C5C6 and C6C7. I went through the invasive protocol path which was pain meds, muscle relaxer, physical therapy, and one epidural injection. Nothing helped and my condition worsened. My strength in my left arm diminished by 30%. Muscle density has decreased in my forearm,tricep,bicep and left pectoral muscle. Hand coordination is compromised along with tremors. On Dec 5th, My orthopedic spine doctor recommended a two level artificial disc replacement with mobi C. I agreed with my doctor . I had to get approvals from my primary physician , cardiologist, and get an ekg and blood work. Though all approved that I was not a risk , it was a pain in the hello to get their office to submit their approval to my orthopedic doctor. So start on Dec16th per pre op instructions I stopped take the pain meds and muscle relaxers. Also had to wash the bed sheets two night before and shower with a special soap. I followed very thing . Now the fun part. Dec 19th I had the pre op conversation with the hospital surgery nurse to collect my medical history.  By 11am I receive a phone call from my orthopedic doctors office. I was told that the pre certiction doctor denied the ADR and would only approve a fusion. I currently have full mobility of my neck . Getting a fusion is obviously going to mess me up especially being as active as I am. Fusion apparently requires following surgeries since it degrades the disc above and below the fused disc. This doctor is in Arizona whereas I’m near Chicago. The reviewing doctor is a internal medicine/ occupational physician over 60 yrs of age. Huh?Thats like having a proctologist’ to review a cardiac procedure. Man ...Aetna is messed up. This doctor first states that the ADR is an experimental procedure that is not covered in my policy. Well I checked the policy and it is accepted. Funny back in 2011 fusion was noted as an experimental procedure that they would not cover. Seems like its all about the money. Doctors denies the higher dollar procedure and they get a bonus.. Well this get better.  My doctor requested a peer to peer meeting to discuss my case. This time Aetna representing doctor in California was an orthopedic doctor who specializes in hand , elbow, arm and shoulder. What no spine experience? Hell the should just hire a call center over seas and have someone with no experience read policies and make recommendations. This is horrible. Well it was denied again and surgery was scheduled for today dec27th. My doctor is appealing again and next surgery date is dec Dec 31st. Yup New Year’s Eve . How many doctors under Aetna umbrella are going to be available to review it this holiday timeframe. I’m throwing the option of cashing in some investments and paying out of pocket to resolve this . Then hire a lawyer and file suit for bad faith. That will obviously cost Aetna a lot more than the ADR procedure. I’m going to see my doctor tomorrow to go over all what’s happened and the path forward. To add to all this I usually get 3-4 hours of broke up sleep hours per night and I have been off the pain meds and muscle relaxers since Dec16 th. That a long frickin time when my pain levels are at 5 for the low and peak to 8 at its worst time. So I guess I could add pain , suffering, stress depression to the suit. Aetna is horrible. Oh I have 5he high deductible plan too. I m close to meeting the whole family deductible of $6K. 



  • Well last minute a Aetna neurologist reviewed my appeal . He agreed with my orthopedic doctors report. So the ADR was finally approved. Surgery scheduled dec31st for two level replacement. Happy New Year

  • L4_L5LL4_L5 Posts: 1,416
    edited 12/28/2018 - 5:14 PM

    Congrats!! Wonderful news!!

    Good luck on Monday. Please keep us posted on your recovery.

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  • I ran into the same problem with my ADR surgery. Denied the first time around by Anthem BCBS. I fought and successfully got it approved. So glad I did. Had surgery last spring and recovered with no loss of mobility or restrictions. Good luck to you.

  • Thanks, This is my first major surgery. I’m excited to get it done to rid me of the horrible pain, yet I’m also a bit nervous. I’m going in tomorrow the 31st. Best thing is no fusion. My doctor did inform me that a fusion is contingency plan if there are any issues. With all the ADR ‘s my doctor did he never has to revert to a fusion. My biggest fear is waking up when they knock me out. I woke during a tonsillectomy, a colonoscopy and an endoscopy procedure. And the locals don’t quickly take affect because my metabolizes its to quickly. I will definitely have a detailed conversation with the attending anesthesiologists. Any good tips for recovery? Thanks

  • My dad used to wake up screaming during the middle of surgeries. But that was back in the 70s and early 80s. You’d think they’d have better ways to prevent that these days.

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  • Well have the ADR surgery today at 2:30 pm. I did not wake up thank god. All when well. I did have the option to go home . Instead I’m staying the night for precautionary measures. They gave me  1 oxcodone. Now I’m wide awake . Might as well stay up for New Years .

    Happy New Year All 

    For me happy New disc and no arm pain year!!!

  • Excellent!! Good luck in your recovery.  :)

  • Doing well . Was discharged from the hospital New Year’s Day. First night sleeping in my bed was difficult . Taking Advil  and norco. Trying to hold out on the pain meds as much as I can. Taking it day by day at an easy pace. 

  • Joel1QJJoel1Q Posts: 332
    edited 01/04/2019 - 10:57 PM

    Joes, I had 3 level lumbar  surgery denied by Aetna for the same experimental the time all the useless PT , 3 injections, rejections by was 8 months from when I was injured until I had surgery.  I ended up needing the instrumentation and thankfully am 100% fused. Good luck with the recovery, stick with your doc’s instructions and you have a better chance of successful recovery. 

    L3-S1 ALIF Feb 2018 and 

    L3-S1 PLIF Laminectomy and Fusion March 2018

  • Joes, Congrates on the successful surgery.   Try to take it easy physically until well after the recovery period, play it safe, take no risks and do the PT, always. I am checking for confirmation that you received a two level disc replacement which means that there are two Mobi-C devices in your spine.  I've known about the devices for 10 years now but didn't know about the application of multiples .  Best of luck going forward.

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