How can I convince my insurance company to approve an artificial disc replacement?

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How can I convince my insurance company to approve an artificial disc replacement?

I am 39 years old. I am scheduled for cervical and lumbar surgery. The insurance company is denying my pre-certification due to the fact my neurosurgeon stated artificial disc replacement is the best for my condition. To the insurance artificial disc replacement is investigational. I do not want fusion. I want my mobility and I do not want to have surgery in 3 or 4 years due to the fusion damaging my other vertebraes. What can I do?

Asked on May 14, 2011 under Insurance Law, Illinois

Answers:

Walter Lindstrom

Answered 10 years ago | Contributor

Our office has handled over 200 lumbar and cervical disc replacement cases all denied on the same basis of experimental/investigational.  We are an advocacy firm and not a law practice.  We only deal with the payer's internal appeal process and the Independent Review Process (IRO) and do not litigate.  Our track record is quite good because (depending on the implanted device) TDR is not "investigational" as that term is defined in all summary plan descriptions/certificates of coverage.  If you do not wish to have the limitations inherent with a fusion you can and should fight the denial knowing it may done successfully.  Good luck.

Mike Harvath / Harvath Law

Answered 10 years ago | Contributor

     Hi.  I am sorry to hear about the issues that you are having with the insurance company in getting them to cover the cost of the artificial disk replacement.  I am an Illinois attorney that focuses my practice primarily in the areas of personal injury, workers' compensation, and disability claims, and I deal with insurance companies daily.

     One of the issues that is relevant here is how your condition developed.  In other words, was it the result of an accident or some type of injury?  In the event that it was, the insurance company may have to pay additional compensation for any continuing disability (such as lost mobility) or future surgeries, in the event they insist on the fusion.  If a settlement can be obtained for an appropriate amount, you may be able to afford the cost of the artificial disk replacement.  There may be the possibility of having an attorney negotiate with the insurer to have them cover the artificial disk replacement surgery, in the alternative.  There is not enough information in your posting to determine how your condition developed.  If it was the result of a specific injury or accident, there may be room for negotiation.

     I can be reached, for your convenience, by e-mail at [email protected].  Thanks.

NOTE: This answer is for educational purposes and does not constitute legal advice.  The use of this site does not create an attorney-client relationship or privilege between the user and the attorney responding.

SJZ, Member, New York Bar / FreeAdvice Contributing Attorney

Answered 10 years ago | Contributor

There may not be anything you can do, unfortunately. You can appeal their decision, using their own interal process; and if that fails, you can hire an attorney to sue them, on the grounds that the technique should not be considered investigational. However, you need to recognize that both are uphill battles or longshots; insurance companies have considerable discretion in what they approve, and if the artificial disc is not yet a standard procedure, they may have good grounds to not pay for it. You should certainly consult with an attorney who specializes in health insurance issue, who can evaluate the situation in detail for you, but you need to recognize that you may not be able to force the insurer to pay; you can always pay yourself, however.


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