I'm going to be interviewed on October 13th for the DVD that the ADR patient foundation I linked to here is producing. Yay!

I'm excited of course to be able to tell my story, but more importantly, this DVD will be used for patient education and will be distributed to spine centers all over the country.

Here I linked to an article in the times that discussed Medicare’s decision not to cover ADR surgery in patients over 60. As it turns out, this is not good news for ANYONE needing ADR, and possibly even fusion. Here’s why.

During my last check up, Theresa mentioned that the pace of their surgery schedule has really slowed as many/most insurance companies are now not paying for the type of surgery I got, that is, ADR combined with a fusion. They’ve narrowed the range of what is covered by adding the stipulation that there can be no other existing conditions, so if a patient needs ONE disc replaced and that’s it, ok. People like me who needed a fusion and a new disc would be shit out of luck. Thank goodness that I got my surgery when I did, as I can’t even think what the outcome might have been if I’d had to wait for even a few more months.

On top of that, I’ve been reading with interest the health care proposals of the three leading democratic presidential candidates (Clinton, Obama, and Edwards). They all seem to include/favor the formation of some kind of “institute” that would research the most effective treatments for the most common (read:expensive) health care issues.

From the NYTimes:

"Along these lines, the three leading Democratic candidates have quietly come up with nearly identical ideas. Deep inside their health care plans, Mrs. Clinton, Mr. Edwards and Mr. Obama have each called for the creation of a national institute to figure out which kinds of medical care actually work. This institute would sort through the scientific research on, say, spinal fusion and help people understand when it may make sense and when it’s likely to be just another big medical expense that doesn’t solve anything."

As back pain is one of the major health care costs, lumbar fusion and I suppose ADR, though the article didn’t specifically mention it, would be researched for their efficacy. Apparently there are some studies that show that fusion is, in some cases, no more successful in treating back pain than other methods. While this is true, and I'm not advocating that anyone and everyone who requests a spinal fusion should be able to get one, I am afraid that the insurance companies will seize on any study that supports a conclusion that means they don’t have to pay for a procedure. The Times article goes on to state that Medicare and the insurance companies would then use the research to “determine when a procedure or a drug would be covered” (read: they’d use the research to deny coverage).

Of course, this is all just my opinion, and wouldn't it be nice if I were proven wrong, but if there's anything I've learned in the past year or so, it's that insurance companies are pretty predictable when it comes to cutting what they cover and putting more of the insurance premiums we pay into their own pockets.

Medicare Denies ProDisc Coverage

From today's Times: This is not good news.

Incidentally ...

Here's the statement from the insurance company for my surgery. As you can see (click on the photo to see it larger), the hospital was allowed just over $71,000 for "incidentals." If you think that is bad, we saw the documentation on the insurance company's website showing that the hospital actually asked for $153,000 for the "incidentals." The fact that they're getting just under half of what they asked for sounds cheesy on the insurance company's part, and luckily, our insurance company did cover those incidentals, no problem, so we don't have to pay.

Still, I'm curious as to just what exactly those incidentals were. I mean incidentals are defined as things that are minor, casual or subordinate. Subordinate to what? Well, things that are not incidentals, but essentials.

So is this charge for things like those little bottles of Keri lotion or the infernal baby powder they are always pushing on you when you are a patient? Actually I think those things are better categorized under "sundries," but there wasn't a category on the statement for that. Anyway, I didn't use the lotion or baby powder, so maybe the insurance company can get the money back? Not that I'm so keen on helping out the insurance company, but then maybe our premiums would go down, or something like that.

Do the incidentals include the use of hospital gowns? Cause I brought my own, so can that be deducted too? The day I was discharged a volunteer came in and gave me a small plant; what portion of the 71K was that little schefflera?

Just the room and board alone was close to $25,000. I could have rented a room at a nice hotel in Philadelphia with that money. I sure didn't eat many meals (read: ONE that wasn't sippable, and there weren't too many of the sippable kind, come to think of it) so there should be a reduction in the "board" amount, too.

I guess I shouldn't be complaining too much, as I said earlier, our insurance company did pay for most of the bill, but I just wonder what kind of world it is where insurance companies will pay $71,000 for "incidentals" but won't approve more than one level of TDR (total disc replacement) when a doctor deems it necessary. As in essential. As in the opposite of "incidental."

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.

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.