queenbee54
07-18-2001, 04:32 PM
My husband's surgeon wanted to do bilateral DBS but the HMO denied it 2 days before the surgery stating bilateral was not under Medicare guidelines. They did a unilateral (under Medicare guidelines) but only the wires and no stimulator yet. We are trying to get authorization for the second unilateral which is in grievance. This means 4 surgeries rather than 2. Has anyone had problems like this or any helpful suggestions? I have called Medicare and searched the internet for guidelines and can't find them. Any help would be so appreciated.
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Googy
07-18-2001, 06:28 PM
This can happen.Bruce who lives in Indiana had to pay most of his DBS.And he isn,t on an HMO.Because of the same reasons from Medicare.Keep fighting it.as he is.
Googy
Googy
Pelicangirl
07-19-2001, 01:36 PM
Hi QueenBee.
First of all, where do you live? Second of all, is this a DBS or DBS-STN? I had 2 operations, on the right and on the left, to implant the DBS-STN appparatus and to put the probe in my brain. It sounds like a long, involved process to have the stimulator added at a later time. I don't know what a Medicare HMO says, but I am on Medicare and, up until now, they have paid a lot of it and my other insurance has paid some. Medicare is my primary.
Good luck to you in fighting this!!!
Pelicangirl (aka Ruth)
First of all, where do you live? Second of all, is this a DBS or DBS-STN? I had 2 operations, on the right and on the left, to implant the DBS-STN appparatus and to put the probe in my brain. It sounds like a long, involved process to have the stimulator added at a later time. I don't know what a Medicare HMO says, but I am on Medicare and, up until now, they have paid a lot of it and my other insurance has paid some. Medicare is my primary.
Good luck to you in fighting this!!!
Pelicangirl (aka Ruth)
Pelicangirl
07-19-2001, 01:39 PM
Hi again QueenBee,
I just looked and saw you were from Upland. I am also in CA, Huntington Beach. I had my surgeries at UCLA. It was a very pleasant experience, if you can say something like that is pleasant. I'm sorry I don't have any advice or help for you, but I just don't know when it comes to the Medicare HMO.
Pelicangirl (aka Ruth)
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I just looked and saw you were from Upland. I am also in CA, Huntington Beach. I had my surgeries at UCLA. It was a very pleasant experience, if you can say something like that is pleasant. I'm sorry I don't have any advice or help for you, but I just don't know when it comes to the Medicare HMO.
Pelicangirl (aka Ruth)
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queenbee54
07-20-2001, 05:28 AM
My husband had his DBS at Good Samaritan through USC. Their procedure was to put the wires in (which would have been both sides of the brain) and the stimulators (one on each side)are normally implanted about 4 days later. Then about 4-6 weeks later they would turn them on. Since it was rather last minute that it was changed from bilateral to unilateral (due to the HMO), the surgeon wants to do the other side of the brain and then put both the stimulators in as another surgery. The HMO medical director wants my husband to have one stimulator put in and see how this works before doing the other side. This is where I am appealing it because the surgeon said only doing one side will not do any good. I am getting more impatient waiting for approval and more confused on whether to go with what the surgeon wants to do or try what the HMO is wanting us to do. Medicare is doing a fully funded study on the bilateral but my husband could not be in the study. It's a sad situation to put anyone through extra surgeries when it could have been two. The unilateral is under Medicare guidelines but I want to make sure the HMO will pay their portion so we are waiting for their approval. I had thought maybe someone else had been through a situation like this because I get so many different answers from Medicare. Maybe others can learn from this case. I will appeal it all the way to the administrative law judge if necessary.
Bruce
07-20-2001, 11:15 AM
Yes, I have been through the same situation. Having more than two surgeries is absolutely insane. Some hospitals, like Ruth's experience, does two surgeries, one for each side. As for my sutgery, it was all done in one surgery, which, in my opinion, is the best way to do it. It went very well for me and I was discharged the following day and I felt great.
It is strongly recommended to have a bilateral STN aurgery, because the side without the stimulator will get worse.
I was so desparate for the surgery that I agreed to pay for it, because in Indiana, it is not FDA approved. Medicare will pay for a unilateral surgery, because they can use the same charge codes that are FDA approved for the older thalamic surgery for tremors.
The DBS surgery has been approved in 27 states. Indiana is not one of those states. That means medicare will pay for a bilateral surgery in those approved states.
I have paid about $25,000 for about half of the surgery, but I am appealing it and they will have a hard time making me give up,
The instructions for the appeal process is on the back of the medicare summary of your bill. I included as much documentation as I could come up with. It is your right to appeal the bill, so I would say go for it.
I have researched this surgery for three years and have never seen anything about doing four surgeries.
Bruce
It is strongly recommended to have a bilateral STN aurgery, because the side without the stimulator will get worse.
I was so desparate for the surgery that I agreed to pay for it, because in Indiana, it is not FDA approved. Medicare will pay for a unilateral surgery, because they can use the same charge codes that are FDA approved for the older thalamic surgery for tremors.
The DBS surgery has been approved in 27 states. Indiana is not one of those states. That means medicare will pay for a bilateral surgery in those approved states.
I have paid about $25,000 for about half of the surgery, but I am appealing it and they will have a hard time making me give up,
The instructions for the appeal process is on the back of the medicare summary of your bill. I included as much documentation as I could come up with. It is your right to appeal the bill, so I would say go for it.
I have researched this surgery for three years and have never seen anything about doing four surgeries.
Bruce
Pelicangirl
07-21-2001, 02:19 AM
QueenBee,
Don't give up fighting. That's what it's all about, somebody sticking up for their rights. I don't see why Medicare won't cover it in some states when they cover it in thers. After all, it's federally funded and should be covered in all states or none.
Bruce and I have different opinions about the surgery, I suppose because we had them differently. I had two unilaterals and he had a bilateral. I have read that it takes your brain some time to heal from one and then they do the other. I know none of this helps you but maybe it will help someone else who is encountering the same situation.
Hang in there QueenBee!!
Pelicangirl (aka Ruth)
Don't give up fighting. That's what it's all about, somebody sticking up for their rights. I don't see why Medicare won't cover it in some states when they cover it in thers. After all, it's federally funded and should be covered in all states or none.
Bruce and I have different opinions about the surgery, I suppose because we had them differently. I had two unilaterals and he had a bilateral. I have read that it takes your brain some time to heal from one and then they do the other. I know none of this helps you but maybe it will help someone else who is encountering the same situation.
Hang in there QueenBee!!
Pelicangirl (aka Ruth)
Lory
07-21-2001, 10:49 AM
Originally posted by Bruce:
Yes, I have been through the same situation. Having more than two surgeries is absolutely insane. Some hospitals, like Ruth's experience, does two surgeries, one for each side. As for my sutgery, it was all done in one surgery, which, in my opinion, is the best way to do it. It went very well for me and I was discharged the following day and I felt great.
It is strongly recommended to have a bilateral STN aurgery, because the side without the stimulator will get worse.
I was so desparate for the surgery that I agreed to pay for it, because in Indiana, it is not FDA approved. Medicare will pay for a unilateral surgery, because they can use the same charge codes that are FDA approved for the older thalamic surgery for tremors.
The DBS surgery has been approved in 27 states. Indiana is not one of those states. That means medicare will pay for a bilateral surgery in those approved states.
I have paid about $25,000 for about half of the surgery, but I am appealing it and they will have a hard time making me give up,
The instructions for the appeal process is on the back of the medicare summary of your bill. I included as much documentation as I could come up with. It is your right to appeal the bill, so I would say go for it.
I have researched this surgery for three years and have never seen anything about doing four surgeries.
Bruce
Bruce, how can I find outif Oregon is one of the 27 Medicare approved states? What reference?
Lory
Yes, I have been through the same situation. Having more than two surgeries is absolutely insane. Some hospitals, like Ruth's experience, does two surgeries, one for each side. As for my sutgery, it was all done in one surgery, which, in my opinion, is the best way to do it. It went very well for me and I was discharged the following day and I felt great.
It is strongly recommended to have a bilateral STN aurgery, because the side without the stimulator will get worse.
I was so desparate for the surgery that I agreed to pay for it, because in Indiana, it is not FDA approved. Medicare will pay for a unilateral surgery, because they can use the same charge codes that are FDA approved for the older thalamic surgery for tremors.
The DBS surgery has been approved in 27 states. Indiana is not one of those states. That means medicare will pay for a bilateral surgery in those approved states.
I have paid about $25,000 for about half of the surgery, but I am appealing it and they will have a hard time making me give up,
The instructions for the appeal process is on the back of the medicare summary of your bill. I included as much documentation as I could come up with. It is your right to appeal the bill, so I would say go for it.
I have researched this surgery for three years and have never seen anything about doing four surgeries.
Bruce
Bruce, how can I find outif Oregon is one of the 27 Medicare approved states? What reference?
Lory
Bruce
07-21-2001, 11:14 AM
Lory, go to the Medtronic website www.medtronic.com, (http://www.medtronic.com,) and get their phone number and call them. They have been very helpful to me, and the reason they should be able to answer your question is they have every patient who has had the surgery in their data base.
Good luck, Bruce
Good luck, Bruce