California Patient Story on Insurance Reimbursement for Artificial Disc Replacement before the use of TPAs:
1) In mid 2007 I knew I couldn’t spend the rest of my life on pain medications, but spinal (cervical) fusion scared me terribly. I wanted to have some choice in what happened with my neck so when my annual renewal for my health insurance came in Oct 2007 I changed to a PPO, HMO’s are too limited.
2) Jan 2008 I got an MRI and went to two Doctors for evaluations. One was a neural surgeon and the other an orthopedic surgeon. They both said I needed a 3 level cervical spinal fusion. They couldn’t guarantee it would take the pain away, but I was in danger of being paralyzed if I waited. This scared me even more. I decided to research other options. I found out about artificial disc replacement (ADR) in Germany. The success rate was much better and there was no risk of future surgeries due to the strain on adjoining discs, like with spinal fusions. I went to a doctor with UCLA and got another evaluation. I got 2 evaluations in Germany, both suggesting ADR. I now had 5 opinions, all saying I needed surgery. I did not want to get a spinal fusion; I had heard too many negative outcomes from cervical fusions. I chose to go with Prof. Dr Bertagnoli for my surgery. * I also got a letter from my primary doctor stating my medical history regarding my neck.
3) One of the surgeons in the USA, without me realizing it, had gotten prior authorization for the spinal fusion. I contacted my insurance company to see if I could get prior authorization for an out of country surgery. They told me they could not give prior authorization for out of country, I asked what they needed to get it covered. They said I needed a synopsis from the surgeon performing the surgery and proof of necessity from him. This was provided before the surgery from Prof. Dr. Bertagnoli and also after the surgery.
4) After my ADR surgery, I sent in an international claim along with Prof. Dr. Bertagnoli’s bill, 2 USA opinions and 2 German opinions (including Prof. Dr. Bertagnoli), my primary doctor’s medical history on me, the prior authorization from the USA doctor and a letter summarizing why I went to Germany for my surgery. **The 3rd USA doctor’s evaluation - I didn’t get his opinion in writing prior to sending in the claim, but I mentioned him in my letter.
5) The claim came back asking for the detailed reports from the hospital. I contacted Dr. Bertagnoli’s office and asked them to send the detailed report. It came to me in mostly German, I sent it in and the claim was approved and I was reimbursed. I didn’t have to appeal my claim at all, just provide more information.
6) I’m not sure what part of my collection of data got my claim approved, perhaps it is merely the fact that if I had the surgery in the USA it would of cost the insurance company three times or more then the surgery in Germany. And future costs of medical and or surgery. Insurance companies must have data following patient’s pre and post cervical spinal fusions?? I’m just very grateful it was covered.
SUMMARY:
A: Change to a PPO Insurance, if not already.
B: Get several evaluations, my insurance company wanted a synopsis and proof of medical necessity from the surgeon performing the surgery, so I got several all with “synopsis and necessity”.
C: Get your primary doctor to write a summary of your medical history in regards to your need for surgery. Helps prove medical necessity too.
D: If you can, get one of your USA doctors to get prior authorization, get a copy of it for your records. Show’s insurance company was willing to pay for the surgery.
E: Write a letter summarizing it all together. **My insurance company stressed to me that I needed from the doctor performing the surgery a “synopsis and proof of medical necessity”.
The time and effort I put into my research and gathering the data was worth every bit of my time. My neck is pain free, perfectly aligned, not in danger of future surgeries, no danger of paralyzing myself and more. Thank you Dr. Bertagnoli!! And your staff, especially Dr. Andrea Fenk-Mayer. AND Tim, for assuring me I was doing the right thing by going to a foreign country for a surgery that scared me more then I can really say. Not a day goes by that I don’t think of the amazing work that was done to my neck and how lucky I was to find Dr. Bertagnoli.
Hey Tim -- I just wanted to let you know that I did receive the revised invoice from ProSpine a few days after your email. I immediately submitted the invoice to BCBS and guess, what? A week later we received a check in the mail from BCBS for $54k!
I thought you might be interested to know that BCBS did pay our claim, as it might benefit some of Dr. B's other U.S. patients. If you are interested, I am happy to share with you the demand letter I submitted to BCBS addressing their position that the multi-level ADR is excluded as "experimental or investigational." I had actually filed a lawsuit against them last week, which will be dismissed now that they have paid the claim. It doesn't appear that they paid as a result of the suit, because they hadn't received notice of it on the date they issued the check. It may be that they intended to pay it all along, but were waiting for the revised invoice. At any rate, Liv and I wanted to send our most sincere thanks for your assistance.
Most important, Liv continues to improve and is doing well after her 3 level cervical ADR. You can add us to the growing list of satisfied ProSpine customers!
Best regards,
John Hyatt
