Degenerative Disc Disease Support Group

i have been diagnosed with DDD since i was 32, 9 years ago. i have had every possible treatment to avoid surgery, and am in pain (in spite of the meds i take) pretty much all the time. i saw a neurosurgeon after my last treatment (RFA) failed, at the suggestion of my pain management doc, and they think that i am an excellent canditate to have a disc replacement done first in my neck at 6/7 and then later in my low back at L5/S1. THey said if i do this, it is very likely that i will be pain free ( i can't even imagine, but i'm very willing to try :).

today, i was notified by my insurance that they are denying the request for pre-certification and will not cover it. it seems ridiculous to me. they have literally paid hundreds of thousands, if not a million dollars or more over the past nine years in pain management, diagnostics, medications, pain control procedures including epidurals, ablations, and injections...diagnosis and treatment of a medication related sleep disorder, and stomach ulcerations due to meds, and the hospitalization and testing to deal with those complications, as well as countless doctors' visits, etc. they are willing to pay for spinal fusion surgery (which would only have me back in to have further levels fused in 5-10 years due to the nature of that surgery) but not pay for a replacement that would actually not CREATE more problems, would eliminate my need for the pain medications, monthly doctor's visits, and a guaranteed continuation of surgeries that will leave me less functional over time. Since i'm only 41, i'd think that they'd be concerned about the projected costs of my health care if they do indeed continue down a path of fusion given the documented outcomes for that 10-15 years down the road.

anyway, does anyone have ideas about how to go about appealing a decision like this?

i find it hard to believe after 9 years of hearing from doctors only how i am basically on a downward spiral of loosing mobility, and increasing pain, with no hope of anything getting better, there is finally a treatment available after completion for which the doctor actually used the words "pain free" and "off medication"--it was like i could have my life back again, then 7 days later, i get a call from my insurance basically saying, nope, you can't have that, we won't pay for it....

i can't pay for it myself--i think it is around $120,000--several years salary for me... but it just doens't make any sense that they would rather take on the costs of managing and perpetuating a problem that they could have solved...

i'd appreciate any insight anyone has. that or i may just have to start rattling a tin cup out on the street corner. i don't know. :(

thanks,

em
Posted on 05/14/08, 03:05 am