A Straight Line

Supposedly the shortest distance between two points is a straight line. Unfortunately, the shortest distance between me and the surgery I need seems to be a more zig-zagged trajectory, involving several different versions of what is to be done to me for the benefit of the insurance company, along with a liberal sprinkling of our cash.

After all the waiting to see Dr. Balderston, after all the anxious days and weeks wondering what was happening to my body, fretting over the insurance company delays and frustrated with not hearing back from anyone in his office, when he walked in and started off with his usual, “talk to me,” I could barely formulate a sentence. I was too terrified of what the answers would be to ask the questions I had. I’d been sick, literally sick to my stomach, for a few nights in a row, worried about the visit, and the outcome.

We looked at the xrays from September, and he showed me where the vertebrae had slid to the side (see picture below, click to see it larger), something that happened just in the last six months or so.



I also saw how the other disc had collapsed completely, leaving the vertebrae to grind together, bone on bone. Just below that was the disc that collapsed unevenly, causing me to pitch forward.

Click to see larger:



When I asked what the possible timeline was, he grimaced, saying he didn’t have a crystal ball, but then started to say something about how they had had “some luck” with some insurance companies by just submitting for the fusion (he had planned to fuse one of my vertebrae, the L3-4 along with putting in the two ProDiscs at L5-S1 and possibly L4-5 if he can pry it apart sufficiently) and then submitting that they were also doing an ADR and would the insurance company pay for the additional operating room time, hospitalization, anesthetic, etc., if the patient paid out of pocket for the surgeon’s fee for the installation of the disc and the cost of the device itself. I realize that he can't come straight out and say these things, but the hints went right over my head. Thank goodness Tyler was there and picked up on it. Once he told Dr. B that we would be willing to do that, Dr. B said they would start working on it right away, adding that it would still be another “few weeks at least.” He also said the insurance company personnel were “evil,” that clerks with little or no medical training were making medical decisions and trying to dictate what kind of surgery I and other patients in my situation would have, but that he would make sure that I got the configuration that I need, even if we have to pay for it (Somehow that sounds wrong, but oh well …).

So now they will resubmit to the insurance company for the fusion and one disc we will pay for the rest. It’s very scary and only partly because of the money we’ll be spending that the insurance company should shelling out. What also concerns me is that he doesn’t think we should wait for the insurance company to fool around, but rather that we should just go ahead and do something now, before it’s too late to do anything. This of course only adds to the anxiety that I already have about every step that I take putting me closer and closer to inoperability and never standing up straight again. He’s penciled me in again for December 6th and hopefully this time the line will go straight from here to there.

Everyone Knows Best

I've got my appointment with Dr. B. tomorrow in Philly though I can't imagine he'll have any good news for me yet as far as the insurance company goes. More on that later.

Last week I had two, count 'em, two doctors appointments. I had to see the periodontist and the podiatrist (my orthotics are literally in pieces in my shoes, not good for someone who has trouble walking anyway). Yes, normally I would only schedule one of these appointments a week since I can't take the excitement of actually going outside of the one square block that I live on too often, but I threw caution to the wind as I thought when I made the appointments that I might be having surgery soon, so it would be a good idea to get all the other stuff out of the way.

I've been putting off all the other little maintenance health appointments (got the eye doctor next week, trying to make an appointment for a mammorgram too) because I just can't bear to explain to anyone else what's going on when they look at me and say, "What happened to you?!" I'm sad and depressed about it and it makes me sadder and more depressed to have to talk about it. So I have to explain as succinctly as possible what is going on and what is to be done about it. Then I have to hear their diagnosis/suggestions/war stories. I guess because back pain is prevalent that almost everyone has experienced it to some degree, almost everyone thinks they are qualified to offer me advice.

The periodontist (gum doctor) suggested I read this book, basically implying that my back problems are all in my mind. I might accept this, except that I've seen my xrays, and they aren't of my brain. As the hygenist was taking off my bib and raising up the chair (which I'd asked her to warn me if she was going to do and she did as she was ratcheting it, grrr!), she said, "So, are you going to get the book?"

That was Tuesday. Friday I see the podiatrist (foot doctor). More explaining about the cane and the way I'm walking, or not, and that no, surgery is not scheduled yet because of Aetna not approving this surgery. His advice? Go to other insurance companies that are approving it and get letters to send to Aetna proving that they are not up to the standards of care of these other companies. He looked at me like he was surprised that I was not writing it all down. I just smiled, nodded and said, "Ok." I didn't even want to launch into the story of how NO insurance companies are paying for it, officially anyway, because he probably would have spent a lot more time lecturing me on how to get around that. But, *sigh* I'm getting very good at steering people away from the subject of my situation and brought up the reason I was there, my orthotics, to divert him.

So tomorrow I see Dr. B. (spine doctor) and hope to at least get some additional information on the surgery since it doesn't seem like there's been any developments on Aetna's side of things yet, as Maureen hasn't called to rub it in, er, I mean tell me about it.

The Queen of Denial

Maureen should not be allowed to talk to patients.

As I said here, according to Maureen, my clain with Aetna will be denied/rejected/refused/disallowed/declined. Then once I get the letter saying a resounding and predicted-numerous-times-by Maureen "NO," I have to decide how I want to appeal. Of course, as you may have read in the last post, this news threw me into a panic. I don’t know the first thing about appealing anything to an insurance company. Do I get an attorney? I’ve seen this kind of thing in movies and on Dateline, no one wins appeals against insurance companies!

So I asked Tyler to call and see what he could find out; he always has better luck getting info. For some reason, none of the staff in Dr. B’s office seem neither to want nor be even slightly equipped to actually communicate with patients. He spoke with the ever elusive Theresa, Dr. B's NP, who tried to immediately transfer him back to Maureen. Once he was allowed to get a sentence out, here’s what she told him about the whole process:

Every insurance company is rejecting any claim for more than one level of ADR. Once they reject mine, Dr. B has attorneys that will handle the appeal and on top of that, he sits on a board that advises insurance companies about the need for surgery, so he's confident that he'll be able to get two levels. In addition, he has several different permutations of the procedure that I need that will get appropriate payment for the hospital (such as charging a bit more for one disc to help offset the cost of the second, etc.) so that I will be assured of getting the two discs I definitely need. If worse comes to worst, Tyler said that we will pay out of pocket for the second disc (buy those t-shirts, people!). It’s all very confusing, not made any less so by the machinations we have to go through to get someone who will actually take the time to look at the big picture and then explain it to us. I guess it is really too much to ask to have someone be a little encouraging and optimistic when speaking with patients who are terrified and in pain, unlike Maureen, the humorless Queen of Denial.

Update

I just had a call from Maureen. She said she heard from the "nurse" at Aetna and that they were sending my file to the Medical Director for review. What does that mean? Maureen said she would be "very very surprised" if the claim was approved because Dr. B. put in for a three level replacement. She said she has never ever seen any insurance company pay for more than one level.

So what's next? She said once they deny it, I'd get a letter saying so and telling me what the appeal process is so that I can proceed with my appeal. My appeal. I asked what that meant and she said that they'd sent all the clinical information to them and on the appeal it was up to me to say what I think the appeal should be. Then she hemmed and hawed and tried to get off the phone. Can anyone explain this?

I'm lost, and sick with discouragement.

Friday morning I get a call from Krista (yes, now I'm naming names!) in Dr. B's office. He had to cancel the appointment for Friday. When she said it I tried not to react, even though my heart fell to my feet again, as it does whenever they call. Tyler says I would be great in a political campaign spinning mundane things about the opposing candidate into the biggest negative news stories because I always immediately think the worst, like they are cancelling the surgery, for what reason I can't imagine, but that's what I think. Anyway, I didn't say anything and neither did she for a few long seconds till she finally asked if I wanted to reschedule. Um, YES? She says the earliest appointment I can get is for the following Friday, the 27th. Of course I agree to it, but I am thinking that October 27th for a follow up appointment does not bode well for an early November surgery date.

Since Maureen (yes, more names! I don't care anymore!) was supposed to call me back at least two weeks ago and never did, I call Tyler and ask him to call and find out what the heck is going on. Also by now the disappointment has set in and I'm crying my head off, not the best frame of mind to try to talk to a doctor's office. Tyler calls and leaves a message and no one calls him back, so he calls again and gets Maureen on the phone. She doesn't remember why she didn't call me back but says that they haven't heard anything at all from Aetna so there would really be nothing to talk about at an appointment anyway. Well, isn't that lovely and casual? It's only a week, right?

No big deal.

Except I was living for that appointment, I was looking forward to it as though it was some kind of a milestone, I thought we'd be in the home stretch after that. A week is an eternity to me, as I'm not getting around too much at all anymore, the days are dragging like you would not believe.

I hate just waiting for time to pass.

There's nothing I can really do until I go to see the doctor next Friday. As I've said before I have mixed feelings about this appointment, on one hand, wanting to go and ask questions and be reassured that I will indeed be having the surgery and perhaps even given a date for it. On the other hand, (and I hate this hand), being told that maybe Aetna hasn't responded, or worse, that they have rejected the request and we'll have to appeal. Last time we were in Dr. B.'s office, he left us with the impression that they knew how to "work the system," meaning they'll wheel and deal with the insurance company to get the operation covered. I hope they know what they're doing.

It doesn't help, either, that I called the woman who is supposedly in touch with the insurance company and is supposed to be coordinating all this to see if there was any other information (like the fact that I was just approved for SSDI) that might help. She said she'd call me back and hasn't, which just makes me crazy. I was saying to my husband the other night that this is just like dating. Do I call back? Why didn't she call me? Maybe she's busy, or maybe she's sick, or maybe I'm never having this surgery and I'll be in a wheelchair soon.

If I got a date for the surgery, then I could start planning; I could start to line up who's going to take care of Tony, maybe get some new pajamas to wear, get my hair cut and my legs waxed in anticipation of a two week hospital stay. But for now there's really nothing I can do except wait for time to pass.

We spoke to Dr. B's office last week with questions about my activities. Last time I spoke with him he told me to stay strong and stretch, but things are going downhill, literally, by the week so I was worried that my efforts to stay active were somehow harming me. Tyler spoke to Theresa who said that pain aside, swimming was good (check) and that I should not be doing anything high impact (yeah, right, there goes that Salsa Step class I was signed up for) or carrying any weights. I've switched my upper body workout from free weights to machines to give me a bit more support, as I'm now afraid that bicep curls have been wearing down my discs. That's ridiculous, of course, I know that, but still.

I go back to see Dr. B on October 20th and I'm terrified that after all this time I'm going to either be denied by the insurance company or my discs will have deteriorated to the point where the disc won't physically fit. I'm anxious beyond belief about this, but all I can really do is wait it out till next week, something I've never been good at.