DBS & Medicare HMO - Parkinson's Disease Message Board

queenbee54 · 07-18-2001, 01:32 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.

Googy · 07-18-2001, 03:28 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

Pelicangirl · 07-19-2001, 10:36 AM

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)

Pelicangirl · 07-19-2001, 10:39 AM

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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queenbee54 · 07-20-2001, 02:28 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.