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: 1,247
    edited 12/28/2018 - 4:14 PM

    Congrats!! Wonderful news!!

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

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  • 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.

  • 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!!!

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  • 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: 364
    edited 01/04/2019 - 9:57 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. 

  • 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.

  • Thanks. Yes I had a two level ADR Mobi c c5c6 c6c7. I  am taking it easy though it’s very difficult since I’m person that can’t sit still. I trying a little reprogramming to prevent going to far.  I have two bright colored wristband for each hand. One has printing “ Don’t do it” and the other “ think about first”;. Sounds corny’s working for me . I would jump right into something to help someone without thinking in a heartbeat. I have a shop garage full of tools and a few hot rods that keeps on persuading me to play . I’m holding off . 

    Physically I feel great. I’m taking Norco every 6-8 hours along with Advil. Sooner off the pain meds the better. I’ll ice my neck if it gets a bit sore. Sleeping like a baby at night which sure beat the 2-4 hours of sleep I was getting pre-op. I do have a foam wedge to raise my back and have a pillow under my knees. Still eating soft foods . My throat still is sore and still feels like I have a lump in it when I swallow. 

    The initial  insurance denial was unbelievable. The radiologist that read the mri stated mid stenosis and degeneration of the c4c5 disc which was above the two herniated disc that were my problem. They felt a fusion was the best solution. My surgeon studied as an engineer prior to getting into  orthopedic medicine. I have an engineering background also. So In the design world if you had a disc above  or below that was what they called out mild generation, why would you induce more torsion on those disc and cause them to fail.

    A fusion does exactly that, whereas the ADR does not. Maybe some of these doctors need  a high school physic class. . Really what I feel is that physician reviewing my case  did not have experience in the orthopedic spine field should not be making decisions based a scripted policy. I was very close to pay for this procedure and follow up legally . I’m thankful I did not have to go that route. It would of been stressful and time consuming. 

    I really did not get a PT instructions post op. The doctor said I could wear the neck brace if I feel the need to ie passenger in my wife’s bouncy Jeep. The therapist did emphasize on no jarring movement, don’t fall, walk on flat even surfaces, use hand rail going up and down stairs, no running or jumping and do not lift anything over 5 lbs. 

    Follow up with my doctor is this coming Wednesday, his plan for me might change. I know for sure recouping is 6-8 weeks prior to performing lift duty tasks. 

  • Looking at my discharge paperwork it does state ibuprofen (Advil) every 4 hours as needed for mild pain.

  • Update. Yes A1btr it’s was a multi level ADR with the Mobi-c. So far everything is going great. Still no lifting over 5 lbs. No running, jumping etc. I am able to drive short trips . The lower neck does stiffen up a bit occasionally. The doctors forbids me to take any anti inflammatory meds. They want inflammation to aid it the bone growth to the hardware. I see the doctor on the 8th . I’m hoping I get the ok to go  back to work. The only thing I’m concerned with is my commute downtown on the train. It’s not the most neck friendly ride with the rocking and hard stops. Overall so far I’m extremely happy with the results and glad I fought the insurance company.

  • I'm so happy the insurance worked out and your surgery was successful. I don't think I could post about the insurance companies with the sensibility and apparent sanity you did. Hope all is going well. 

  • Hi Joes, I am devastated with the news I received today - surgery for ADR denied by my private insurance, Anthem Blue Cross. Any suggestions on how to appeal? I am in a workers comp case, which makes everything more complicated. Workers Comp has approved fusion for my C5/6-C6/7 and I am refusing fusion (as you had mentioned, I also have a passion for outdoor activities). I do NOT want to have any restrictions or problems with the levels below or above which fusion can cause. I am an avid competitive runner - been running since second grade. I have only been out of commission in the past for a meniscus repair - had surgery and was back on the trails shortly after. Now, I have been out of commission for 162 days. NO ONE understands my constant pain and that my neck can barely hold up my bowling ball of a head. I have done physical therapy, chiropractic, and their ridiculous medication. I don't want drugs and want to be fixed. How can they say "it's not medically necessary" and that is why I am told it was denied. I have an attorney... whole 'nother story. I just am sick about getting it denied by my private insurance. My pain is exasperated from crying all afternoon. Any suggestions are beyond appreciated. 

  • Hi Joe,

    I m going through a similar situation right now. 

    Any guidance is much appreciated!

  • @zoeys the original poster hasn’t been online for nine months so maybe consider starting your own new thread.

  • Sorry I have not been on this site . Work has shipped me all over the world. Every thing is going great . Yes there is some stiffness which is tolerable . The upper disc did fuse which may happen . The dr said when they do a fusion they expect bone growth whereas a disc replacement  they don’t expect it and it grows. 

  • Thanks for the update @Joes. Glad all is going very well.

  • My orthopedic surgeon is a long time friend. He did help me through the whole ordeal. The key item I had was an MRI scan of my neck back from 2006 . The doctor who wrote my 2019 MRI reported that the disc above my damaged disc had slight to severe  degeneration . Well this same doctor wrote my 2006 report which stated slight - moderate degeneration. The upper disc did not change over 13 yrs. The other thing I did was find out the insurances consulting doctors that were reviewing my case. Once I got the names I checked out each doctors background and their expertise . One of the physicians reviewing my case was a occupational / internal medicine doctor , one a orthopedic doctor that specialize in shoulder , arm and knees, and last was a neurosurgeon that obviously was the one that pushed to approve the ADR. I was willing to fight the insurance company with lawyers . My doctor advised me to be patient and not go the legal route . He said I would spend lots of money and I wouldn’t win. He did write it was medically necessary since my arm strength decreased 50% , there was a loss of feeling in my fingers , and the muscle tone in my left chest area was reducing . I never gave up the fight . It’s amazing how the insurance approves the ADR yet your company paying may state it’s an experimental procedure . Hope this helps . Joe

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