Second unilateral denied - Parkinson's Disease Message Board

queenbee54 · 07-27-2001, 12:46 AM

Today I received some sad news from my husbands HMO insurance that denied a second unilateral DBS. As I had explained on a previous post, his surgeon wanted to perform a bilateral DBS and the insurance denied it stating bilateral is not under Medicare guidelines and therefore is not covered. The doctor then performed a unilateral in May with the intent to do another unilateral on the other side. Now the insurance states that medical documentation they received on my husband indicates the first implant appears to be for bradykinesia and akinesia, not tremor. They said local policy concerning DBS is specifically approved for the treatment of upper extremity tremors that have failed conservative medical management. My husband just turned 55 and was recommended for bilateral DBS because his meds have not been working well anymore no matter what they have tried with his Sinemet (reg and CR). He has balance problems and has fallen many times, often has uncontroled jerking of the muscles, and then goes through periods of stiffness with heavy feeling in the legs and can barely walk without extreme difficulty and exhaustion. I have been advised by his surgeon at USC and read info on the internet about DBS-STN that have helped these symptoms. I am still new to speaking on message boards but I appreciate the replies I received and find other postings so beneficial. I would so much like to hear from anyone who has had DBS or know someone who has to let me know if it was just for tremor or did it help other symptoms. Maybe there are also sites you can recommend that I can refer to for this because I can not give up as frustrating as it is I will continue to appeal the insurance's denial. I need documentation of it helping anyone with symptoms other than just tremor. The sad part is that my husband has to suffer more because of a medical director's decision.

Googy · 07-27-2001, 03:26 PM

Hi what a lot of misinformation they are giving you.They know nothing.Ruth" Pelican girl" is on vacation now but if I remember rightly never had a tremor. Also Bruce didn't.She had hers at UCLA.Bruce of course is still fighting Medicare.
You have to still appeal this,but you have to get back to the surgeon who did the first part and re submit it.
They make me so angry.I can imagine how your husband feels.

Hang in there,

Googy

Carrotcake · 07-27-2001, 07:32 PM

DBS helps bradykinesia, rigidity and Tremors. However, as far as reimbursement from Medicare is concerned, it has ONLY been approved for payment for tremors. They are still in the process of approving payment for other symptoms in this case the surgery is titled DBS-STN. There ARE some states that are already paying on DBS-STN. The problem is finding out if your state is one of them. Only thing I can recommend is talking to the surgical coordinator and/or the reimbursement analyst assigned for the surgery dept to find out if your state's Medicare intermediary has approved payment for the DBS-STN surgery that your husband's doctor has recommended. Hope this helps.

Lory · 07-29-2001, 07:52 AM

Quote:

Originally posted by queenbee54:
Today I received some sad news from my husbands HMO insurance that denied a second unilateral DBS. As I had explained on a previous post, his surgeon wanted to perform a bilateral DBS and the insurance denied it stating bilateral is not under Medicare guidelines and therefore is not covered. The doctor then performed a unilateral in May with the intent to do another unilateral on the other side. Now the insurance states that medical documentation they received on my husband indicates the first implant appears to be for bradykinesia and akinesia, not tremor. They said local policy concerning DBS is specifically approved for the treatment of upper extremity tremors that have failed conservative medical management. My husband just turned 55 and was recommended for bilateral DBS because his meds have not been working well anymore no matter what they have tried with his Sinemet (reg and CR). He has balance problems and has fallen many times, often has uncontroled jerking of the muscles, and then goes through periods of stiffness with heavy feeling in the legs and can barely walk without extreme difficulty and exhaustion. I have been advised by his surgeon at USC and read info on the internet about DBS-STN that have helped these symptoms. I am still new to speaking on message boards but I appreciate the replies I received and find other postings so beneficial. I would so much like to hear from anyone who has had DBS or know someone who has to let me know if it was just for tremor or did it help other symptoms. Maybe there are also sites you can recommend that I can refer to for this because I can not give up as frustrating as it is I will continue to appeal the insurance's denial. I need documentation of it helping anyone with symptoms other than just tremor. The sad part is that my husband has to suffer more because of a medical director's decision.

Please keep trying. I am going to be 55 in September, so can understand, truly, a lot of your and your husband's frustrations. I'm not a candidate for surgery yet, but avidly read this board for cotinuing information,date, resources, and especially the rsults of peopel's DBS/STN surgeries. Please keep us posted, and I'm sure you will get many replies to your post, with good information for you. Lory

Pelicangirl · 07-31-2001, 01:08 PM

Hi Queenbee,

I am on vacation and using my son's computer so I'm not real sure this will get there, but here goes.

I had my surgery done at UCLA and it was the DBS-STN, although I don't think the doctors wrote it up that way. All I ever saw on the forms was DBS. Maybe that's where they're going wrong. Anyway, I had bradykinesia, rigidity, dyskinesia, but never had tremors. The DBS alone is for tremors, but the DBS-STN is for everything else plus tremors. Maybe they would pay for a second unilateral if it was only written up as a DBS.

Pelicangirl (aka Ruth)