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Thread: Surgery option eliminated due to Insurance denying Forteo for Osteo

  1. #1
    Join Date
    Jul 2011
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    Nashville, TN
    Posts
    177

    Surgery option eliminated due to Insurance denying Forteo for Osteo

    Well, it looks like any possibility that I had for surgery is probably gone now since insurance will not cover the Forteo that is required in order to have a good surgical outcome. Gone are all hopes of living a decent quality life with my 10 yr. old twins. Insurance denied it initially, Dr. office wrote a letter of medical necessity explaining that this is required in order to receive a positive surgical outcome with osteoporosis. Insurance has denied based on "did not meet established prior authorization criteria defined by your prescription plan; current plan criteria only allows coverage of Forteo for a diagnosis of primary osteoporosis if patient" has a history of osteoporotic fracture; has failed or is unable to tolerate other available osteoporosis therapy, or has more than 1 risk factor for fracture". I am such an idiot for assuming for months now that I was going to be able to have this surgery even though I have osteoporosis. I feel like such a fool.

  2. #2
    Join Date
    Oct 2007
    Location
    Indiana
    Posts
    1,978
    Don't give up all hope yet. Sometimes your doctor can continue to push. And you can call and write letters and explain the situation. Keep on fighting. Sometimes it could be a matter of them not understanding the facts/situation. And sometimes it could also be that you need to talk to different people. Keep fighting for yourself. I'll be praying for you. I know this must be super frustrating and disheartening, to say the least. Just don't give up all hope. Hugs...
    Last edited by Susie*Bee; 08-20-2011 at 12:01 PM.
    67 and plugging along...
    2007 52 w/ severe lumbar stenosis & L2L3 lateral listhesis (side shift)
    5/4/07 posterior spinal fusion T2-L4 w/ laminectomies and osteotomies @L2L3, L3L4
    Dr. Kim Hammerberg, Rush Univ. Medical Center in Chicago

    Corrected to 15
    CMT (type 2) DX in 2014, progressing
    NEW 10/2018 x-rays show spondylolisthesis at L4/L5 - Dr. DeWald is monitoring

    Click to view my pics: pics of scoli x-rays digital x-rays, and pics of me

  3. #3
    Join Date
    Jul 2011
    Posts
    535
    There are other meds that folks have taken in addition to taking a non-med route using supplements. Linda, the forum moderator, posted a while back how she took supplements and turned her results around. Press your surgeon for options because there is a way. Many prayers for you.

    Warmly,
    Doreen
    44 years old at time of surgery, Atlanta GA

    Pre-Surgery Thorasic: 70 degrees, Pre-Surgery Lumbar: 68 degrees, lost 4 inches of height in 2011
    Post-Surgery curves ~10 degrees, regained 4 inches of height

    Posterior T3-sacrum & TLIF surgeries on Nov 28, 2011 with Dr. Lenke, St. Louis
    2 rods, 33 screws, 2 cages, 2 connectors, living a new life I never dreamed of!

    http://thebionicachronicles.blogspot.com/

  4. #4
    Join Date
    Jul 2011
    Posts
    535
    For those of you who are currently or have in the past been prescribed Forteo, who was your surgeon? Have any of you been initially denied by your insurance but then approved by your insurance? What was done/said to your insurance to change their decision?

    Warmly,
    Doreen
    44 years old at time of surgery, Atlanta GA

    Pre-Surgery Thorasic: 70 degrees, Pre-Surgery Lumbar: 68 degrees, lost 4 inches of height in 2011
    Post-Surgery curves ~10 degrees, regained 4 inches of height

    Posterior T3-sacrum & TLIF surgeries on Nov 28, 2011 with Dr. Lenke, St. Louis
    2 rods, 33 screws, 2 cages, 2 connectors, living a new life I never dreamed of!

    http://thebionicachronicles.blogspot.com/

  5. #5
    Join Date
    Jun 2011
    Location
    Southern CA
    Posts
    2,262
    Maybe look to change your surgeon. Find someone who will do the surgery now

    Melissa
    Melissa

    Fused from C2 - sacrum 7/2011

    December 8, 2014 - Another Broken Rod Surgery

  6. #6
    Join Date
    Jul 2011
    Location
    Nashville, TN
    Posts
    177
    Hate to be so stupid, but anyone have contact information for the forum moderator Linda? I don't get an e-mail address
    through the "contact us" at the bottom. Anyone have her e-mail?
    Last edited by TwinmomTN; 08-19-2011 at 09:00 PM. Reason: additional info

  7. #7
    Join Date
    Sep 2003
    Location
    Northern California
    Posts
    7,104
    After I was diagnosed with osteopenia, I went on a high calcium diet, supplemented with 2 or 3 different types of calcium daily. It took a few years, but my last two DEXA scans were completely normal.
    Never argue with an idiot. They always drag you down to their level, and then they beat you with experience. --Twain
    ---------------------------------------------------------------------------------------------------------------------------------------------------
    Surgery 2/10/93 A/P fusion T4-L3
    Surgery 1/20/11 A/P fusion L2-sacrum w/pelvic fixation

  8. #8
    Join Date
    Jul 2011
    Location
    Nashville, TN
    Posts
    177
    Linda, do you mind sharing what your osteopenia score was? I didn't know it was possible to improve it without meds.

  9. #9
    Join Date
    Jul 2011
    Posts
    535
    Your insurance stated: current plan criteria only allows coverage of Forteo for a diagnosis of primary osteoporosis if patient" has a history of osteoporotic fracture; has failed or is unable to tolerate other available osteoporosis therapy, or has more than 1 risk factor for fracture.

    What is their definition of "risk factor for fracture?"

    Have you asked your surgeon for an alternate med? I've heard some folks here have taken Evista which, according to my insurance plan, does not require the special pre-authorization from the insurance carrier. If you surgeon can get you on another med and it works, great. If the other med doesn't work, then wouldn't you qualify under your insurance statement of "...has failed or is unable to tolerate other available osteo therapy?"

    Just trying to help you think of options.

    Warmly,
    Doreen
    44 years old at time of surgery, Atlanta GA

    Pre-Surgery Thorasic: 70 degrees, Pre-Surgery Lumbar: 68 degrees, lost 4 inches of height in 2011
    Post-Surgery curves ~10 degrees, regained 4 inches of height

    Posterior T3-sacrum & TLIF surgeries on Nov 28, 2011 with Dr. Lenke, St. Louis
    2 rods, 33 screws, 2 cages, 2 connectors, living a new life I never dreamed of!

    http://thebionicachronicles.blogspot.com/

  10. #10
    Join Date
    Oct 2007
    Location
    Indiana
    Posts
    1,978
    Yes, I took Evista and also 1500 mg of calcium with vitamin D (2 500 mg in the AM and 1 in the PM) and my dexa is normal now. I just stopped the Evista but will continue with the calcium. It did take a few years though...
    67 and plugging along...
    2007 52 w/ severe lumbar stenosis & L2L3 lateral listhesis (side shift)
    5/4/07 posterior spinal fusion T2-L4 w/ laminectomies and osteotomies @L2L3, L3L4
    Dr. Kim Hammerberg, Rush Univ. Medical Center in Chicago

    Corrected to 15
    CMT (type 2) DX in 2014, progressing
    NEW 10/2018 x-rays show spondylolisthesis at L4/L5 - Dr. DeWald is monitoring

    Click to view my pics: pics of scoli x-rays digital x-rays, and pics of me

  11. #11
    Join Date
    Sep 2003
    Location
    Northern California
    Posts
    7,104
    Quote Originally Posted by TwinmomTN View Post
    Linda, do you mind sharing what your osteopenia score was? I didn't know it was possible to improve it without meds.
    -1.5

    --Linda
    Never argue with an idiot. They always drag you down to their level, and then they beat you with experience. --Twain
    ---------------------------------------------------------------------------------------------------------------------------------------------------
    Surgery 2/10/93 A/P fusion T4-L3
    Surgery 1/20/11 A/P fusion L2-sacrum w/pelvic fixation

  12. #12
    Join Date
    Sep 2003
    Location
    Northern California
    Posts
    7,104
    Quote Originally Posted by LindaRacine View Post
    -1.5

    --Linda
    I just found the report from my last DEXA. The T-scores ranged from 1.1 to 1.4.
    Never argue with an idiot. They always drag you down to their level, and then they beat you with experience. --Twain
    ---------------------------------------------------------------------------------------------------------------------------------------------------
    Surgery 2/10/93 A/P fusion T4-L3
    Surgery 1/20/11 A/P fusion L2-sacrum w/pelvic fixation

  13. #13
    Join Date
    May 2009
    Posts
    3,745
    i have osteopenia...and was told it would not prevent my having the
    fusion surgery...

    i did not know any of it was reversible...to me, that is pretty amazing...
    but i am wondering if it is osteopenia that is changeable...not osteoporosis....

    is there a limit to how much calcium one may take...?
    are there side effects from taking a lot of calcium...?
    just wondering...i am going to start looking this stuff up on the internet...

    jess

  14. #14
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    Mar 2008
    Location
    New Bern, NC
    Posts
    1,445
    Quote Originally Posted by jrnyc View Post
    i have osteopenia...and was told it would not prevent my having the
    fusion surgery...

    i did not know any of it was reversible...to me, that is pretty amazing...
    but i am wondering if it is osteopenia that is changeable...not osteoporosis....

    is there a limit to how much calcium one may take...?
    are there side effects from taking a lot of calcium...?
    just wondering...i am going to start looking this stuff up on the internet...

    jess
    Jess, I think even osteoporosis is reversible. Yes, you can overdose on calcium and it would cause cardiac problems according to my PCP back in Massachusetts. Go to the best websites on the internet such as WEBMD or the MAYO Clinic, not just any website.

    TwinmomTN, There are several medications that are now generic that will help reverse osteopenia.

    Sally
    Last edited by loves to skate; 08-20-2011 at 04:09 PM.
    Diagnosed with severe lumbar scoliosis at age 65.
    Posterior Fusion L2-S1 on 12/4/2007. age 67
    Anterior Fusion L3-L4,L4-L5,L5-S1 on 12/19/2007
    Additional bone removed to decompress right side of L3-L4 & L4-L5 on 4/19/2010
    New England Baptist Hospital, Boston, MA
    Dr. Frank F. Rands735.photobucket.com/albums/ww360/butterflyfive/

    "In God We Trust" Happy moments, praise God. Difficult moments, seek God. Quiet moments, worship God. Painful moments, trust God. Every moment, thank God.

  15. #15
    Join Date
    May 2009
    Posts
    3,745
    thanks for the info, Sally

    jess

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