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Old 03-22-2005, 08:19 PM   #1
Junior Member
Join Date: Dec 2004
Location: NJ
Posts: 18
Caz72 HB User
Insurance balking at ADR

Well, here I am still waiting for the insurance company to approve my surgery. *My* problem is that they don't want me to get the disc replacement, but instead, opt for the fusion. *Their* problem is that I refuse to let them tell me what to do, and will fight them to the bitter end on this one. I have had 2 lami's that worked for a while but then the disc popped again both times. I now have strictly back pain (leg is good) but its unbearable at times.

I have done everything they said. Two weeks ago, they sent me to their doctor with a representative from their company that sat in on the appointment. Their doc said straight up that I am an ideal candidate for the disc and he thinks I would do well with it. Then yesterday, the same insurance rep accompanied me to my doc (whom is their doc too), who basically told her the same thing -- Disc replacement is my best option and fusion would be second best.

For some reason, she still didn't seem like she thought it would get approved despite the fact that BOTH doctors and I believe it is the better of the 2 surgeries for me. The funny thing is that the disc replacement procedure is less expensive than the fusion that they want me to get. There is no reason for them to deny me the medical care I desire and deserve, but there's a good chance they will anyway, according to their rep. I will be extremely angry if they deny me. I should know in 2 weeks according to their rep. She needs to write a report and along with the 2 doctors reports, send them to their medical director. The medical director who has never seen nor spoken to me is going to make a decision on my care. What a joke.

In the meantime, he I sit, in pain.

Moral of the story: if you want the disc replacement, it won't be easy to get for a few years, unless you want to pay for it yourself.

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Old 03-22-2005, 08:27 PM   #2
Join Date: Dec 2004
Posts: 1,291
Quietcook HB UserQuietcook HB User
Re: Insurance balking at ADR


Is this for a workman comp insurance coverage? I'm new to an insurance rep going and actively being involved in a doctor's visit except under workman comp claims. Even then, I agree with you though, that it is your body and you have the right to make the determination with the doctor of your choice as to what will or will not be done. None of us need non-medical experts being a major part of that decision and certainly not making the decision for us, unless they want to accept the pain that we are suffering.

Sure hope you soon get the approval for the surgery you and your doctor are requesting. Let us know how things are progressing.

Old 03-22-2005, 08:39 PM   #3
Junior Member
Join Date: Dec 2004
Location: NJ
Posts: 18
Caz72 HB User
Re: Insurance balking at ADR

Thanks for your response, QC. It is a workers comp claim. But from the way she explained it and my doctor as well, they are turning down all requests for adr. Has anyone here successfully gotten insurance to pay for the disc replacement?

BTW.. I've been working every day, all along just living with the pain, walking crooked, and taking breaks when I need them. I'm also not taking any pain meds because they make me ill. I'm not trying to scam the system or get meds for the wrong reasons. I'm not saying that others do this, but the lady that accompanied me said there is so much fraud going on that this is the reason why it's so hard to get things approved. I hope they will be able to see this for what it is and do the right thing. I just want the proper surgery that I am entitled to, and that's the ADR, according to me and the doctors.

Old 03-22-2005, 09:07 PM   #4
Join Date: Dec 2004
Posts: 1,291
Quietcook HB UserQuietcook HB User
Re: Insurance balking at ADR

Oh, I do understand that there are people out there who will try to scan any system in existence, and it makes it extremely difficult for the rest of the people A shame indeed.

It's good that you've been going on as much as you can, but difficult with you not being able to take the pain meds. Still, if you have anyone representing you, they need to point out that you should not be denied what is proper for you and what your doctors recommend because someone else is doing wrong. Treating you wrongly by denying you proper care which will allow you the best chance for the fullest recovery possible does not fix their sytem! If they deny you what will give you the best chance at returning to normal, then they may wind up taking care of you for a long, long time. Sure hope that is not the case, because getting back to normal is best for all, especially you.

Keep us up on how you are doing.

Old 03-23-2005, 01:58 AM   #5
Senior Veteran
Join Date: Apr 2004
Location: Fl
Posts: 571
Bionicwan HB User
Re: Insurance balking at ADR


just wanted to applaud you on your efforts & convictions!

I think it is shame how the ins companies "try" to dictate our care, makes me wonder sometimes if it's the $ they're worried about - how much are they burning on red tape - PEOPLE ATTENDING DR'S APPT'S w/ you that must cost duh,....I am sorry this is happening to you and I think it's pathetic. Most likely they're biggest thing is the "supposed newness" of the ADR - while only recently approved here, it has enjoyed major success in Europe and other countries. Like the NEW drugs they ALWAYS cost more til the hype dies down. The US is the best country in the world but SURE has a long way to go with the healthcare system.

keep us posted and GOOD LUCK!


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