Complaint 1 of 5 in “Experimental Treatment”

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  • Insurance Carrier: Meritain Health - Healthlink
  • State: IL

Consumer Complaint:

I have a torn vertebral disc at the L4-L5 level that has caused moderate to severe back pain for over two years. The surgeon wants to perform a disc replacement and the insurance won’t pay – they WILL pay for a fusion. I had a previous fusion at L5-S1 about 15 years ago and it also needs repaired (it has come loose). Insurance says disc replacement is investigational so they will not pay. I want the recommended surgery because the doctor knows my situation as a physical education teacher and avid sportswoman. Please help

Insurance Expert Answer:

We are aware of a Stanford faculty member's report on a study just concluded that showed that at the end of 4 years patients with surgery (and I think they were talking about dislocated disk at L4) fared no better than those who had therapy but without surgery, although those who had the surgery had faster decreases in pain.

They also showed a new technique they used that was far less radical than fusion or disc replacement -- done under a microscope -- with far better results.

I mention this only to share something helpful with you and to tell you there is a reason insurance companies resist paying for what one's doctor (who of course has financial and other incentives to operate as \"it's what we do/like to do\") recommends. Very often the empirical results are very unconvincing.

To convince your insurance company that the procedure your doctor recommends is not investigational you'll need him/her to show you that the medical literature has accepted the procedure as mainstream. Approval by the FDA, VA, articles in peer reviewed medical journals, professional boards, etc. are all very useful in convincing your insurance company that what they regarded as an investigational no longer is.

One other approach that sometimes works is showing them that the cost savings to them of the path of treatment you seek is FAR less expensive and will actually save them considerable money. (They likely will reply \"that is not a concern here\" or \"our concern is long term health of our clients and not having to pay for a second operation and/or complications of investigational methods if this does not perform as expected. BUT it may have just enough impact to tilt the odds in your favor a bit.)

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