Guaranteed Healthcare

This is the second time I have written here about my so-called health insurance, Blue Cross of California Premier PPO. The first was after Blue Cross denied additional physical therapy sessions for me, despite the fact that my physician sent them a letter of medical necessity. Now I am faced with an insurance hell. Six days before a planned surgery, Blue Cross denied surgery for an artificial disc implantation or disc arthroplasty. This was on Wednesday, Jan 23, 2008. The lumbar artificial disc by Synthes Spine called Prodisc was approved by the FDA in August, 2006. It is one of two FDA-approved lumbar discs available, the other being the Charite.

The surgery my neurosurgeon planned to do involved an anterior (front) approach, bypassing the peritoneum and moving the aorta and illiac veins to get to the vertebra at L4/L5. Once there, they take out the old disc and put in the artificial one—some what like when someone gets a knee replacement but in a different area. It is major surgery, requiring a vascular surgeon to open me up. It is disconcerting enough to prepare for this kind of surgery without being told a few days before that it is cancelled because Blue Cross deems it “investigational”. I had already gone through pre-op testing, donated a unit of autologous blood, had appointments with four physicians and arranged my schedule prior to the expected operation date.

Never mind the mental preparation. My husband had requested time off of work so he could be home when I was hospitalized and take care of our four children in addition to me once I came home. I went though some major undertaking to prepare for the surgery and it all came crashing down on me Wednesday when my doctor's office called me with the news. My hands are still shaking while I write this. It is difficult to comprehend back pain unless you have gone through it; even as a nurse, I didn't understand it fully. It is with you all the time and it doesn't come and go, It is a 24/7 thing. To give you some background: I originally injured myself at home, or I thought so, by lifting sheet rock. The pain and muscle spasms started two days later. As a critical care nurse, I typically lift heavy weights during a shift. So when I woke up with back pain on May 24, 2007, I thought it was sore muscles. I had no idea this was a start of a nightmare that would put me out of work for months.

Five days later, experiencing muscle spasms and difficulty walking, I went to my primary physician, who prescribed rest, Predisone, the muscle-relaxer Flexeril and physical therapy. He told me I had a muscle strain and it should get better soon, he didn't think the possibility of me needing surgery was evident, but he mentioned it as a remote possibility. As the pain continued, and Tylenol wasn't helping that much and neither were NSAIDs, I kept asking him and my physical therapists, “Are you sure this is a muscle strain?” They answered yes. And I said: “It doesn't feel like any muscle strain I have ever had.” I guess back pain is like a process, you can go weeks without the correct diagnosis. Since I was not improving after 3 ½ weeks of treatment, a month after my initial injury, my doctor sent me to a physical rehabilitation and pain doctor (Dr. E). An MRI on June 27, confirmed this doctor's suspicions, showing a 4.5 mm herniated disc at L4/L5.. Of course I didn't get the news until the next week when my doctor called me.

I was put on more steroids, continued physical therapy and told not to sit for more than 20 minutes at a time, lift more than 15 pounds and generally 'take it easy'. I walked after I got his approval and felt better and I did PT. That was the extent of my exercise. It was restrictive for a competitive masters track athlete but I followed it. Eventually, as I didn't improve and in July, developed numbness and tingling in my feet and legs, I underwent a series of injections—two epidural spinal injections and one facet joint block.. They served a dual purpose as they were therapeutic and diagnostic. Dr. E told me he was looking for my 'pain generator'. A discogram—which has no relation to the Disco craze of the 80's—was performed on October 4, 2007, showed I had Degenerative Disc Disease (DDD) and I had tears in the disc between L4/L5. I was positive at that level in what is called a provocative pain test. Under fluoroscope, Dr. E. injected dye into my lumbar discs to pressurize each disc. It is a blind, randomized test and Dr. E tested three discs. It is an extremely painful test to say the least. After the test, I got a CT of the discs. Dr. E had found my pain generator. My doctor, who had assured me in the past that I was not a surgical case, gave me the bad news: I needed surgery.

What kind was up for debate, depending on which doctor you talked to. The way things happened is a lot more complicated than that. Back pain is not simple. After seeking three spinal surgeon opinions, I decided to go to a neurosurgeon (Dr. P) who I trusted because I had taken care of his patients and because he had been one of my doctors after a car accident 22 years before. I had my first appointment with him on October 25, spending a long time filling out a detailed questionnaire, speaking to Dr. P's physician assistant and then Dr. P came into the room. He cut to the chase—I needed surgery. His first choice was disc replacement, second, an anterior lumbar interbody fusion (ALIF).I was not eligible for an outpatient “easier” surgery called a micordisectomy, where they take out part of your disc, a minimally-invasive surgery. After explaining the procedures briefly, he sent me on the way and with prescriptions to undergo tests to rule me in or out for disc replacement.

My DDD at one-level, met the FDA criteria for disc replacement, but that was just one thing to meet. I researched DDD and surgical treatments over the Internet and talked to people with back pain and what they did. Went on the Internet, to hear what people had to say about each treatment. I underwent a DEXA bone scan, flexion and extension X-rays and was denied an MRI by Blue Cross. At first, I was against disc replacement and than as I read people's personal testimonies and pondered the data about the discs, I changed my mind.

On November 20, 2007, I learned that I met all the criteria for disc replacement and I was ready to take it on. Surgery was scheduled for December 26, and then cancelled three weeks before because the unavailability of the vascular surgeon.On the phone, to the officer manager, who took messages for the doctor, I broke down sobbing, telling the doctor's office I needed stronger pain medication because I couldn't take it anymore. I had been on Ultram and Darvocet, but it just dimmed by pain. I had difficulty thinking I could last another week with the pain I was experiencing, let alone weeks. I was placed on Percocets (oxycodone) then.

Surgery was re-scheduled for January 29, 2008. We had met our out-of-pocket maximum for insurance in 2007, not including the five months of PT I had—that we paid cash for and every surgeon I saw recommended, the same PT Blue Cross had denied. Fast-forward to now—we are strapped for cash as we have spent thousands on medical expenses. We start over the New Year with a new deductible and out-of pocket maximum which took months to meet in 2007. Through my husband's employer, we contract with Blue Cross to provide a service for a fee. We feel they are reneging on their promise to provide service. We (me and my husband) can not pay out-of-pocket for disc replacement.

We don't have money to fly to Germany to have disc replacement (ADR) as many Americans have done when they were denied treatment in the United States. Does the movie, Sicko, come to mind? Then I am denied the surgery I need by someone who doesn't know me as some anonymous doctor says Blue Cross considers it 'investigational'. It doesn't matter to them artificial disc replacement surgery has been performed in Europe for more than 20 years (since 1984) and trials were started in the United States in the late 1990's. The date gleamed from the trials was good enough for the FDA to recommend it as a proven surgical treatment. Among the insurance companies that cover ADR surgery are Aetna, Cigna, Kaiser, workers comp, and the federal government. The military, I have learned are putting ADRs into Iraq war veterans.

What is wrong with this picture? Blue Cross will pay for fusion, which according to my doctor is a more invasive surgery, and more recovery time is needed, but won't pay for an FDA-approved surgery that is less-invasive. Granted fusion is the 'gold standard' having been done for many years, but insurance companies are blocking ADRs and preventing the American public from using new technology. Fusion locks in the bone at a level, and prevents motion. ADR is motion preserving and is thought to prevent adjacent disc deterioration. Talking to doctors, a fusion surgery now, will mean additional surgery 10-15 years down the line. I don't want another surgery in my 50's or 60's. I am thinking what can I do? We appealed the decision, but Blue Cross is not known to reverse their non-certifications. They have no interest in stories about human suffering, they only look at their bottom-line. I think they need to look at me.

My appetite has dwindled, and the past nights, I haven't been able to sleep much—actually for weeks. My husband tells me I am deteriorating at the old age of 46. I take blood pressure medicine because of back pain, Percocets for the pain, Flexeril at night, sometimes Darvocet, Gabapentin for sciatica, Celebrex for inflammation and pain. Back in May, I was running five to six days a week, enjoying life, working as a critical care nurse—an occupation I love—and doing the normal day-to-day things a mother of four children does. Now, I don't go out much as I can't drive while I am on narcotics. I don't do other things, either. I am depressed and I feel like the situation is hopeless.

I can't believe the state of health care in America now. But I shouldn't be surprised, because I had already lost a battle with Blue Cross in 2007, when I took my case for additional PT to the Department of Health to an Independent Medical Review, only to have them side with the insurance company. I told the IMR in a letter that I had the misfortune to seek PT treatment for another injury (leg) and then injured my back a few days after that treatment had ended. Two separate injuries; one where it slightly bothered me, but was interfering with my ability to lift my right leg and one that has left me wishing I was dead. The doctor stated in the IMR that the May injury was a 'flare-up' of the previous leg injury. It didn't matter that I explained the situation thoroughly. That was the final decision and we were left with the decision to continue PT because every surgeon I saw said to do so.(We finally ended PT with the New Year since surgery seemed to be around the corner)

Who is working for the patients and not the insurance companies? I wonder if anybody's voice can be heard against the giant health care insurers? I am not getting fusion—which several people have reluctantly resorted to because they were desperate from the on-going pain-- instead of disc replacement because I do not want to be pushed into a surgery by Blue Cross I do not want. What am I going to do? I'll fight Blue Cross, hoping to have them turn-over their decision, but wondering what I'll do if they don't. But I'll try because that's all I can do now. I have 23 days to do it, until the next scheduled surgery date of February 19, 2008. Sincerely, Kim R. Kutcher, BA, ASN, RN, CCRN