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Appeal process is beginning, but I am in incredible pain!

Hi all, this is my first post. I am on the computer late at night while my husband is drifting off to sleep. My spine surgeon's office has received notification that my 2 level cervical disc replacement surgery was denied by Aetna. My peer review was also denied. Their basis is that anything more than a 1 level replacement is "investigational". 

I contacted the Mobi-C Advocacy group. Since my pain level is so incredibly bad, I have requested a letter from my surgeon's office to request Aetna expedite my appeal. The numbness in my had is increasing. Should know by the end of the week if my surgeon can get me that letter. 

In the meantime, which could be months, I am very concerned over what I should do about my pain level. I feel like someone is torturing me with hand tools on my neck, it is truly awful. I am on a lot of meds at this point because it has been quite awhile now that I have been dealing with this. I am frustrated. I feel like nothing is really helping me anymore. 

I don't know what to do about the pain level, as my doctor feels that the 10mg of Norco twice a day is too much for me (I agree but don't know what else I can do), so he reduced me to 45 a month. I take Gabapentin and Soma. I asked him about anti-depressants or any other type of medication I could use instead of these because these are not working, and he told me that other meds can cause brain damage. I realized after the appointment that he probably thought I was just trying to get stronger meds (which is not the case-actually was trying to find something that was just different). 

Has anyone had experience with expediting an appeal with Aetna? I am only 30 years old and am too young to have this problem, it's the result of an injury. What do any of you do when the pain meds, stretching, exercise, etc are just not working anymore? How would you handle a doctor who was concerned about your requests? I don't know what to do, the pain is killing me and I am afraid of how long the appeal process can take. I know you are all going through the same problems so I was hoping someone had some kind of advice.
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13

Comments

  • SongJinSSongJin Arizona Posts: 245
    Oh my gosh I am so sorry, I literally just went through nearly exactly what you did--terrible, stressful appeals process for a Mobi-C ADR with Aetna, and I'm 32. Mine was only a 1-level and I still lost my peer review and request for an expedited appeal! It was a total nightmare--if you search my name you can see some of the craziness I went through trying to deal with this. 

    In my case, my myelopathy was increasing too fast, and both surgeons I was working with advised that I not wait any longer for appeals, so I ended up having an ACDF instead :( 

    Talk to your surgeon about how long you should wait vs. exploring other surgical options and what the trade-offs would be. I was majorly depressed about losing my ADR case, but I was also tired of being in pain and both surgeons said I was risking permanent damage by waiting any longer for an appeal that might ultimately be denied anyway. 

    I wasn't on narcotics prior to surgery, but I experienced the same issues getting adequate pain control, crappy doctors that think you're drug seeking, etc. Do you have a specific pain management doctor? Or can you get medication directly from the surgeon? 

    Feel free to PM me because I literally just lived through this whole process and I feel for you! 
  • Do you have the option of paying cash for the second artificial disc? I went with a one level ACDF because that was the surgical opinion with which I felt most comfortable, but one of my pre-op consults wanted to do a two-level ACDF combined with an ADR above.  He told me flat out that no insurer would pay for a combo ACDF and ADR and that I would have to pay $5,000 cash for the ADR implant.  I would have done that if I had felt that was the best thing for me medically.  I understand that not everyone is in that position, but frankly insurance companies suck and if you want topline care, you might have to fund it yourself.
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  • SongJinSSongJin Arizona Posts: 245

    L.A.Spiney said:
    Do you have the option of paying cash for the second artificial disc? I went with a one level ACDF because that was the surgical opinion with which I felt most comfortable, but one of my pre-op consults wanted to do a two-level ACDF combined with an ADR above.  He told me flat out that no insurer would pay for a combo ACDF and ADR and that I would have to pay $5,000 cash for the ADR implant.  I would have done that if I had felt that was the best thing for me medically.  I understand that not everyone is in that position, but frankly insurance companies suck and if you want topline care, you might have to fund it yourself.

    Speaking of which, depending on your financial situation, ADR is still more common in Europe, and a lot of people travel there to get the surgery done over there with these "celebrity surgeons." That was definitely not an option for me. I can't put the link here because it will get removed, but there's also a specific ADR support forum (just Google for it) and they have a ton of experience with all things ADR specifically. Not as active as this forum, but super nice people that have been through all this stuff too with the insurance hell. 
  • Two level acdf is no longer considered experimental and has been given a regular cpt code instead of an experimental one. Is the doc providing the right codes to the insurer? 
  • Sorry, that should have been cpt codes. The new one for 2nd level is, I believe, 22858. First level, 22856. If they use the old codes that end with t, they'll deny. Those are for experimental procedures. The codes changed last year. 
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  • SongJinSSongJin Arizona Posts: 245
    There may be some other criteria they're using to deny it. In my case, it's because I have small, non-surgical herniations at other disc levels. Because of that, they qualified my case as experimental as well, even though only one of the levels was surgically bad. So there's a few things that they can use to deny your case. 
  • sara.gsara.g CaliforniaPosts: 43

    L.A.Spiney said:
    Do you have the option of paying cash for the second artificial disc? I went with a one level ACDF because that was the surgical opinion with which I felt most comfortable, but one of my pre-op consults wanted to do a two-level ACDF combined with an ADR above.  He told me flat out that no insurer would pay for a combo ACDF and ADR and that I would have to pay $5,000 cash for the ADR implant.  I would have done that if I had felt that was the best thing for me medically.  I understand that not everyone is in that position, but frankly insurance companies suck and if you want topline care, you might have to fund it yourself.

    My surgeon advised me that almost all of the time this is offered, that the insurance will refuse to pay afterwards. That insurance considers it as they approved one level only, and did not approve the two level surgery to take place. I don't know how to communicate this as well as my surgeon's office, but everyone else I've spoken to about this idea has said that there would be a post-surgery denial.

    I would love to pay for the second level myself. Are you saying that you had a 3 level disc issue? I might have to bring this up to my surgeon because mine is very likely 3 levels, otherwise the 3rd is still bulging (I am in so much more pain now then my last MRI a year ago that I would not be surprised at all if the third level has herniated).
  • sara.gsara.g CaliforniaPosts: 43

    olywombat said:
    Two level acdf is no longer considered experimental and has been given a regular cpt code instead of an experimental one. Is the doc providing the right codes to the insurer? 
    Is this specific to certain insurers?
  • sara.gsara.g CaliforniaPosts: 43

    olywombat said:
    Sorry, that should have been cpt codes. The new one for 2nd level is, I believe, 22858. First level, 22856. If they use the old codes that end with t, they'll deny. Those are for experimental procedures. The codes changed last year. 
    The codes I am seeing are : 95861, 95926, 22858, 95925, 22856



  • Is this specific to certain insurers?
    Nope. The temporary CPT codes were deleted and new primary codes issued. 
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