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gardenia
08-06-2012, 05:10 PM
I just got a call from Dr Bridwell's office that they just received a 25page memo on covering BMP in any spinal surgery. That if it is used, the entire operation will be denied not only the use of the BMP.

So my date of Oct 16th is on hold until Dr Bridwell finds a solution. Apparently, BMP has worked very well with lots of success and he does not feel that I would do well by not using it.

Anyone else had this happen? Does other insurances cover BMT?

Needless to say, I am devastated. BMP cost about $100k

Gardenia

rockycarm
08-06-2012, 05:50 PM
Sorry, but what is BMP?

Confusedmom
08-06-2012, 06:05 PM
BMP=bone morphogenic protein. It's a biotech product used in conjunction with your own bone and cadaver bone to speed fusion. Lenke uses it routinely. His nurse told me sometimes if insurers deny coverage of BMP the hospital will eat the cost of it. But the insurer has to agree to cover the surgery. What was the reason for denying the whole surgery if BMP is used? I wouldn't lose hope yet. They're pretty good at getting insurers turned around over there.

Evelyn

gardenia
08-06-2012, 06:42 PM
I was told by the nurse that the 25pg just arrived. I hope that they are reading and re-reading it. She asked me not to call my insurance as not to raise a red flag and that the hospital will help but only if I don't have insurance.

What is funny about this is that the insurance clearly says if BMP is used then nothing involving the surgery will be covered. The office has not done a pre-authorization for me yet as they need to understand how this would affect the surgery.

I thought I could pay out of pocket thinking that it would be a couple of thousands but not at $100k. At least is not like I have a fatal illness - nothing that Vicoden can't help at this stage. It seems like the world just crashed but I am better now. I am still healthy and walking. I can look great after a shower, lipstick, a nice dress etc. knowing that I can still function well.

I am sure that Dr Lenke will have the same document. Dr Bridwell has been using this BMP for over 7 years (I think)

REad this:
http://beckersorthopedicandspine.com/spine/item/9539-how-are-spine-surgeons-using-bmp-today?-9-surgeon-responses

golfnut
08-06-2012, 08:50 PM
Healthlink denied coverage for BMP, but Dr. Lenke assured me that Barnes would absorb the cost, which they did. Healthlink was fantastic with all other coverage and I only paid $250 out of pocket. I hope you can get this issue resolved.

LindaRacine
08-06-2012, 09:49 PM
There was a similar problem about 3-6 months ago, with another insurance company. The insurance company eventually backed down and reversed the policy. Hope that happens with UHC as well.

--Linda

susancook
08-07-2012, 01:09 AM
I believe the same thing happened to Doreen....see her blog about her surgery. Like Linda said, they eventually approved the procedure and the hospital ate the cost of the substance.
Susan

Doreen1
08-07-2012, 09:52 AM
Hi Gardenia,

I had the same exact issue with the same exact insurance company and this "hiccup" occurred hours before we were given the green light for my central line procedure. Here is what Dr. Lenke had to do, start reading at this page http://thebionicachronicles.blogspot.com/2011/11/settled-in-st-louis-however.html

It will work out, have Bridwell's nurse talk with Kelly at Lenke's office.

Warmly,
Doreen

gardenia
08-07-2012, 04:03 PM
Doreen,
Thanks for the post. I am so useless in this blog because I am not sure if I place a title it that will start a new thread or not.

I read what happened to you and I have been reading your blogs and love our exercise and getting out of bed videos.

However, I could not find where you talk about how it was resolved with the insurance. I know that Drs and their nurses are in constant communication. So, I am sure that this is a new document written in a different way all to make patients more frustrated.

I am hoping that they can circumvent this roadblock because Bernie said she had to fight the insurance 7 years ago and need to get up to speed as to how the new procedures are. If one insurance does this then others will follow. Dr Bridwell will not use something used a decade before. How is he going to publish the next paper saying that because of insurance lack of 'brains' that he now knowingly will perform a surgery which he believes is inferior without the use of BMP.

Just guessing and having faith that the group at CAM/Barnes-Jewish will not take this laying down. Bernie said that this is not final and that they are going to be working in a prompt resolution (of course if it will affect a lot of their patients..)

gardenia

yacpatty
08-07-2012, 06:18 PM
Hi Gardenia....Just read your post and wanted you to know I will be praying this is resolved. I now have an Aug 27 surgical consult. Gosh, now I am concerned about Aetna Medicare....fingers crossed.
Patty

jrnyc
08-07-2012, 08:00 PM
gardenia, when you read Doreen's blog, go to the
title list on right side of page...look at the two above the one
titled "Settled in St Louis"....inlcuding the one titled "Green Light"...
that will explain what happened....apparently, they can maybe get
away with not paying for the BMP, as mentioned elsewhere by
other patients....but then they end up covering all the rest of the surgery, and patient pays for BMP themselves, or the hospital absorbs
the cost of the BMP....
probably best ones to deal with these insurance folks are the
surgeon's staff, who probably have to deal with them all the time...
plus, surgeon's staff are not so emotionally invested as the
patient is...

good luck...sounds like it has been worked out before, so it
should be do-a-ble again....

jess...& Sparky

gardenia
08-08-2012, 09:56 AM
I followed your instrucition mainly looking at the name of the blog and found everything to read.

I am hopeful but in the past, the insurance would not cover BMP only. Now, it is not covering anything with BMP. I have been reading articles, of course researching, that BMP has possible side effects eg cancer. That would not be great...

Doreen1
08-08-2012, 10:10 AM
My blog states:

"The Plot Thickens
Met with Dr. Lenke this morning who is shocked that our insurance is not cooperating. In fact, he said he has never experienced this before. It seems the explanation of denial was lost in several translations, but now boils down to this. Dr. Lenke always uses a product called BMP (bone morphogenetic protein) because it provides a faster, stronger fusion for his patients. Dr. Lenke forewarned me back in September when we met that most insurance companies deny the BMP portion of the surgery. Washington University absorbs the BMP cost. My insurance has decided to deny the entire surgery because of the BMP; so they are not just denying the BMP portion but everything.

What makes things more challenging for me is that we must have some sort of "surgery only" approval from the insurance company today before close of business because of the holiday tomorrow and Lenke's office being closed on Friday. The clock is literally ticking in the final countdown. Jeremy has escalated as far as he can on our end and now we are waiting for Dr. Lenke to have the peer-to-peer chat with the insurance company directly."

It was Lenke's peer-to-peer chat with United Health that reversed their decision. Glad the videos are helpful. Keep us posted on the outcome of your insurance.

Warmly,
Doreen

jrnyc
08-11-2012, 05:57 PM
Gardenia, i would call AARP on Monday...
if, as i suspect, AARP recommends UHC for their members, then
they should be interested in what that insurance company
is putting spinal patients thru when surgery is needed....
i would call and try to speak to whomever at AARP is in charge of that
department....

jess

gardenia
08-20-2012, 11:22 AM
As I read your post regarding pre-0p approval, I got confused a bit. I have the date that you joined the forum and the date you posted in response to my thread.. Your signature says surgery Nov 2011.

I wonder if a peer to peer chat would do the job. Sure that Bridwell and Lenke are in the pool so it would be silly for me to call Bernie and tell her (?) as this is 9 months old and United HCare had time to be more detailed on this document? I am making myself wait as I believe that the office does not want to submit a pre-op approval until later and closer to the date of surgery otherwise the insurance would come back for some other ways to deny.

Doreen1
08-20-2012, 02:09 PM
As I read your post regarding pre-0p approval, I got confused a bit. I have the date that you joined the forum and the date you posted in response to my thread.. Your signature says surgery Nov 2011.

I wonder if a peer to peer chat would do the job. Sure that Bridwell and Lenke are in the pool so it would be silly for me to call Bernie and tell her (?) as this is 9 months old and United HCare had time to be more detailed on this document? I am making myself wait as I believe that the office does not want to submit a pre-op approval until later and closer to the date of surgery otherwise the insurance would come back for some other ways to deny.

Hi Gardenia,

Correct, I joined this forum in July 2011 and my surgery was Nov 2011. I don't know what the "normal" process is for a surgeon to try and change an insurance company's stance, but Kelly of Dr. Lenke's office and Dr. Lenke, himself, told me they had never experienced this before where the entire surgery was being denied.

How long has it been since you've talked with Bernie? I recommend talking to Bernie and say to the effect, "...a patient of Dr. Lenke's had this same issue in late Nov 2011... Dr. Lenke resolved the issue with a peer-to-peer call with UHC..." Since Lenke and Bridwell are in the same practice, it may be helpful for Bernie to know how Kelly and Dr. Lenke resolved the hiccup.

Keep us posted on the outcome.

Warmly,
Doreen

gardenia
08-20-2012, 02:29 PM
I will but since Bernie called me as I returned from a month of testings in St Louis, (immediately the following Monday) because the practice recieved a 25pg document from the insurance company to which she said to give them time to resolve this. Her advise is to not contact the insurance myself as they have not submitted my pre-op approval yet.

I wish I could read the content of that 25 pg document but it would mean nothing to me as their practice is well equipped (I hope) to circumvent whatever roadblock.

Does anyone know how close to the surgery date does a physician request the pre-approval? I know that it does not take very long (less than 2 wks?) Maybe, they are preparing before submission.

I will call her again but feel bad doing it...

gardenia

jrnyc
08-20-2012, 02:48 PM
Gardenia
i am so sorry you are going thru all this stress caused
by an insurance company...

would you consider starting a thread asking fellow forum
members to call/write to AARP to tell them what is going
on with United, and that they will reconsider getting United
insurance because of what they are doing about spinal
surgery....?
personally, i need to find a new company in about a year....
and i will, on my own, write to AARP and let them know
i must reconsider my choice based on United's treatment
of spinal surgery patients....

do you have ANY objection to my doing so...?
i will not mention any names...

jess

gardenia
08-20-2012, 05:54 PM
Gardenia
i am so sorry you are going thru all this stress caused
by an insurance company...

would you consider starting a thread asking fellow forum
members to call/write to AARP to tell them what is going
on with United, and that they will reconsider getting United
insurance because of what they are doing about spinal
surgery....?
personally, i need to find a new company in about a year....
and i will, on my own, write to AARP and let them know
i must reconsider my choice based on United's treatment
of spinal surgery patients....

do you have ANY objection to my doing so...?
i will not mention any names...

jess


Hi Jess,
I would be totally OK with you doing this yourself but it will be hearsay from hearsay.

The reason that I have not is because we have the insurance thru my husband's work and it is quite a good plan. I am an AARP member but I do not have the same motivation. I hope this could be resolved in a good way between the surgeon's office and our insurance plan. We have plan coordinators that we could use and they would have to review the data that I am not even privy to.

Without knowing or seeing the 25pg document, I would not be complaining correctly because all I know is what Bernie told me. Maybe, there could be mis-interpretations or different plans or companies receive different coverage. At this time, I am in wait and hope that my chances be good. I hope that those backing WashU can fight fairly as this is why they do research and BMP (off labeled) has been used for many in posterior fusions the this institution. At least, it is not the one-man business operated surgeon that would just move to the next patient in line (I sincerely hope and maybe kidding myself).

You never know what would happen from one year to another and the insurances can do or cover as they see fit. I have no real data in my hands.

jrnyc
08-20-2012, 06:37 PM
well, since you have no objection....
i am going to bring it up when i write/call United....
i have work related insurance now, but it is much more expensive
since i retired...it also opts to pay almost nothing since i had to take
Medicare when i went on disability....i pay alot for both me and my husband,
but get lousy coverage...so i will be looking to change in a year and a
half or so....and i sure do not want to pick an insurance company that
is able to get away with rejecting an entire surgery based on BMP...
we have all heard of insurance not covering BMP, but they pay for
all the rest...
i hope the surgeon's office is able to work it out for you...

jess...& Sparky

gardenia
08-22-2012, 01:09 PM
well, since you have no objection....
i am going to bring it up when i write/call United....
i have work related insurance now, but it is much more expensive
since i retired...it also opts to pay almost nothing since i had to take
Medicare when i went on disability....i pay alot for both me and my husband,
but get lousy coverage...so i will be looking to change in a year and a
half or so....and i sure do not want to pick an insurance company that
is able to get away with rejecting an entire surgery based on BMP...
we have all heard of insurance not covering BMP, but they pay for
all the rest...
i hope the surgeon's office is able to work it out for you...

jess...& Sparky


Dear Jess and Sparky,
My doctor has not submitted pre approval to UHC so I don't want my name coming up or records flagged. However, it would be legitimate for you find out about this situation if you require an operation say next year. You will want to understand what is covered and what's not so that when looking for a specialist you are not wasting your time going to someone who will prefer or work solely with BMP on their toughest cases. I know that they will not use it in adolescent or younger patients.

My husband was regretting that I would not seek advise years ago but years ago was not in my destiny. I could not even consider having my spine touched when I was functioning as well as I could. But, this year the pain started and in my case it has come rapidly not by stages. For years, I could take a Vicoden and be fine. Last night I tried 2 vicodens at dinnertime and was worse as I could not sleep unitl 3am.

I like to hear if they would give you an answer because even if you get a pre-approval they will claim that is not total assurance of payments as if they like when they feel like denying a portion or all, they will. That is just like playing poker or negotiating at a street bazaar but you can't walk away and not buy. They won't give you a price until you are willing or have the benefits on hand.

gardenia

jrnyc
08-22-2012, 02:13 PM
i am not sure as yet whether i would require BMP...
i would be having modified minimally invasive procedure,
rods from posterior, and discs from side...
i have not yet scheduled another appt with NYC surgeon
i would use...i am extrememly ambivalent about the whole thing,
even though my lower curve has supposedly gone from 61 to 70
degrees in 2 years, per latest X ray....i do know my DDD is getting
worse, but we thought my curves were "stable"
the top curve remains about 42 degrees and causes much less
pain than lumbar curve....

i hope Lenke's office can work things out for you to go ahead
with the surgery....

jess...& Sparky

Confusedmom
08-22-2012, 11:11 PM
Gardenia,

In light of our discussion of BMP usage on the other thread, I am even more curious to know what this 25-page ruling from United said. I wonder if Bernie or United would send you a copy. I hope it doesn't have anything to do with this cancer scare/controversy. But I am curious whether the insurer is fighting the off-label use of BMP. My insurance company changed the year before my surgery, but previously was United. Kelly in Dr. Lenke's office told me that United was one of the most difficult ones to get approval from, but that they almost always worked it out one way or another.

Evelyn