My wife has been dealing with pain for 5 years. She has degenerative disc disease and needs disc replacement surgery. Unfortunately, our current health insurance doesn’t cover this because they see it as experimental. We need to find a plan that can accommodate her existing condition and covers CPT Code 22857, which is for a Lumbar 5 Sacral 1 total disc arthroplasty. We talked to a doctor today who advised against using ibuprofen anymore because of her long-term use. Now, she’s really struggling with pain management. Does anyone have tips on how to search for insurance plans that will cover this procedure? We need to get her signed up soon with November coming up.
Talking to the doctor and the billing staff is a good move. Most doctors know which insurance plans work best for their patients. If the doctor doesn’t have the info, the billing team should be able to help you.
I assume she needs a replacement for the thoracic vertebrae or a hybrid artificial disc with spinal fusion, both of which are often seen as experimental. The FDA approved artificial disc replacements for cervical vertebrae in 2005 and for lumbar in 2007.
Most insurance plans will not cover experimental surgeries, so I think asking the doctor about which insurance companies have been successful is smart.
You might want to check online for medical policy bulletins for CPT 22857. Just because there’s a policy doesn’t mean it’s automatically covered, often, it requires prior authorization. It usually outlines the criteria for coverage too. For instance, I found some info on UHC and Aetna. You could see if your wife meets their medical necessity criteria, which might help you get started.
Edit: Oops, I got mixed up about the forum.
Has she gotten a second opinion? There are also other pain management options. I’ve had 3 back surgeries myself, so I understand how frustrating this can be.
@Milan
How much time was there between your surgeries? I’ve been dealing with this for 40 years since my injury. I avoided surgery, which I might regret now, after doing a lot of reading on lumbar surgery.
@Onyx
I waited 9 years between my first discectomy and my second. Then only 2 years between my second discectomy and needing a spinal fusion. I have a connective tissue condition that makes me extra flexible, and I was in a physically demanding job, which is probably why my second didn’t last long. If you do decide on surgery, I recommend a neurosurgeon who specializes in spinal surgery rather than an orthopedic surgeon, but that’s just my take.
@Milan
Thanks for the tip.
Just to add, the surgery will cost $45,000 out of pocket. I know back surgery doesn’t always guarantee relief, but she needs some help. We’re in our 20s, and I can’t stand seeing her in pain every day, it impacts our entire lives.
@Will
Keep in mind that many insurance plans require trying other treatments first for lumbar surgery.
Onyx said:
@Will
Keep in mind that many insurance plans require trying other treatments first for lumbar surgery.
Yes, we’ve heard that. She has already tried physical therapy, pain management, chiropractic care, and acupuncture. Sadly, none of those worked well.
@Will
Just be prepared that the new insurance might require her to go through those treatments again, at least the physical therapy and probably weight management too. Not saying it’s guaranteed, but don’t be surprised if they do.
Good luck with everything.
I think this comment is off-topic.
Echo said:
I think this comment is off-topic.
This isn’t a place for diet or medical advice.
Echo said:
I think this comment is off-topic.
I think I need to rethink my earlier comments.