We are often asked by US Patients, “Will Dr. Bertagnoli take my medical insurance?” The short answer is yes. Historically, we have received payments from Blue Cross Blue Shield's Blue Card Worldwide and other insurance companies for US patients. They must pay the full amount that we charge and they must pay in advance. Because of long delays in payment, we will no longer accept a Letter of Commitment to Pay from the insurance company as sufficient payment prior to your procedure. Prepayment by the patient and reimbursement to the patient by the insurance is the normal method, when dealing with insurance companies. Lately, we are increasingly relying on Third Party Administrators (TPAs) to facilitate payments to the patients, as their reimbursement.

The tough question is “Will your US medical insurance company cover the procedure?” Of course, Pro Spine cannot answer that question for you; it is a matter between you and your insurance company. However, the use of the TPAs has greatly increased payment for artificial disc replacement, facet joint replacement and TSMS), but there are notable exceptions.

It is important to note that the insurance information provided here is mostly for the artificial disc replacement and for patients trying to get reimbursement on their own.

However, Dr. Bertagnoli does many types of complexspine surgery. Indeed he takes many severe cases, which no other doctor will. He has even replaced the entire lumbar spine of a patient! These cases need the TPAs ever more so than the ADR patients.

International workers and their dependents often get coverage for all our procedures. Such examples are oil workers, US State Department workers, US military members, and their families. Aetna, Blue Card Worldwide, Tricare Insurance for military personnel and dependents (Dr. Bertagnoli is ranked as the No. 1 provider for spine surgery for the soldiers and families), and the US State department have already paid for surgery with Dr. Bertagnoli. Moreover, we see some success with patients getting reimbursement for medical expenses before state insurance boards. We have yet to see success in the courts because a patient sued their insurance company to cover the procedure.

How to proceed to take your case before your insurance company or your state insurance board:
1. Document everything.
2. Get a letter of medical necessity, which will include the doctor’s findings and recommendations.
3. Get the ICD-9 (diagnostic) codes and the CPT (treatment) codes for your case.
4. Call the Synthes patient hotline at 1-800-895-7754 or 1-866-223-0508, if you receive a Prodisc implant.
5. Use the research papers available under Dr. Bertagnoli's publications to show your insurance companies the efficacy and research behind the ADR surgery.

Useful Information for the Cervical and/or Lumbar Patient

Diagnostic Codes for Artificial Disc Replacement

(Note: Often multiple ICD-9 (International Classification of Disease - 9) codes and CPT codes are used in submitting cases for remittance.
http://www.icd9data.com is an excellent source of ICD-9 coding information
https://catalog.ama-assn.org is an offering for CPT codes
Coding may have regional variations and is the prerogative of the surgeon)
Possible ICD-9 codes for artificial disc replacement:
721.0 Cervical spondylosis without myelopathy
722.0 Lumbar spondylosis without myelopathy
722.52 Special code for Lumbar degenerative disc disease for Medicare or Medicaid claim
722.71 Interveterbral disc disorder with myelopathy; cervical region
722.72 Interveterbral disc disorder with myelopathy; lumbar region
722.10 May also be appropriate
738.4 Acquired Spondylolithesis (may be used for ADR or fusion)
737.3 Scoliosis and Kyphoscoliosis
737.30 Idiopathic Scoliosis and Kyphoscoliosis

ICD-9-CM Procedure Codes for Artificial Disc Replacement:

Note:ICD-9-CM (Clinical Modifications) is an extention of the ICD-9 code)

84.62 Insertion of total spine prothesis, cervical
84.64 Insertion of total spine prothesis, lumbar

CPT Codes (for treatment) for Artificial Disc Replacement:

22856 - Total disc arthroplasty (artificial disc) anterior approach, including discectomy to prepare interspace (other than for decompression) single interspace: cervical
22857 - Total disc arthroplasty (artificial disc) anterior approach, including discectomy to prepare interspace (other than for decompression) single interspace: lumbar
0091T - for one level ADR (recommended by Synthes)
0092T - for each additional level of ADR
62290 - for discography (72295 may also be used)
62291 - for each additional level of discography (72285 may also be used)

Possible ICD-9 codes for DSS (Dynamic Stabilization System)

Possible procedure codes for Paradigm Spine's DSS and other procedures associted with DSS and independent procedures can be

Denial of Coverage

We strongly recommend the use of the Synthes Appeal Letter, if you are denied coverage. It provides an excellent outline of the steps to take for your appeal.

California Patient Story on Insurance Reimbursement for Artificial Disc Replacement before the use of TPAs:

1) In mid 2007 I knew I couldn’t spend the rest of my life on pain medications, but spinal (cervical) fusion scared me terribly. I wanted to have some choice in what happened with my neck so when my annual renewal for my health insurance came in Oct 2007 I changed to a PPO, HMO’s are too limited.

2) Jan 2008 I got an MRI and went to two Doctors for evaluations. One was a neural surgeon and the other an orthopedic surgeon. They both said I needed a 3 level cervical spinal fusion. They couldn’t guarantee it would take the pain away, but I was in danger of being paralyzed if I waited. This scared me even more. I decided to research other options. I found out about artificial disc replacement (ADR) in Germany. The success rate was much better and there was no risk of future surgeries due to the strain on adjoining discs, like with spinal fusions. I went to a doctor with UCLA and got another evaluation. I got 2 evaluations in Germany, both suggesting ADR. I now had 5 opinions, all saying I needed surgery. I did not want to get a spinal fusion; I had heard too many negative outcomes from cervical fusions. I chose to go with Dr Bertagnoli for my surgery. * I also got a letter from my primary doctor stating my medical history regarding my neck.

3) One of the surgeons in the USA, without me realizing it, had gotten prior authorization for the spinal fusion. I contacted my insurance company to see if I could get prior authorization for an out of country surgery. They told me they could not give prior authorization for out of country, I asked what they needed to get it covered. They said I needed a synopsis from the surgeon performing the surgery and proof of necessity from him. This was provided before the surgery from Dr. Bertagnoli and also after the surgery.

4) After my ADR surgery, I sent in an international claim along with Dr. Bertagnoli’s bill, 2 USA opinions and 2 German opinions (including Dr. Bertagnoli), my primary doctor’s medical history on me, the prior authorization from the USA doctor and a letter summarizing why I went to Germany for my surgery. **The 3rd USA doctor’s evaluation - I didn’t get his opinion in writing prior to sending in the claim, but I mentioned him in my letter.

5) The claim came back asking for the detailed reports from the hospital. I contacted Dr. Bertagnoli’s office and asked them to send the detailed report. It came to me in mostly German, I sent it in and the claim was approved and I was reimbursed. I didn’t have to appeal my claim at all, just provide more information.

6) I’m not sure what part of my collection of data got my claim approved, perhaps it is merely the fact that if I had the surgery in the USA it would of cost the insurance company three times or more then the surgery in Germany. And future costs of medical and or surgery. Insurance companies must have data following patient’s pre and post cervical spinal fusions?? I’m just very grateful it was covered.

SUMMARY:

A: Change to a PPO Insurance, if not already.

B: Get several evaluations, my insurance company wanted a synopsis and proof of medical necessity from the surgeon performing the surgery, so I got several all with “synopsis and necessity”.

C: Get your primary doctor to write a summary of your medical history in regards to your need for surgery. Helps prove medical necessity too.

D: If you can, get one of your USA doctors to get prior authorization, get a copy of it for your records. Show’s insurance company was willing to pay for the surgery.

E: Write a letter summarizing it all together. **My insurance company stressed to me that I needed from the doctor performing the surgery a “synopsis and proof of medical necessity”.

The time and effort I put into my research and gathering the data was worth every bit of my time. My neck is pain free, perfectly aligned, not in danger of future surgeries, no danger of paralyzing myself and more. Thank you Dr. Bertagnoli!! And your staff, especially Dr. Andrea Fenk-Mayer. AND Tim, for assuring me I was doing the right thing by going to a foreign country for a surgery that scared me more then I can really say. Not a day goes by that I don’t think of the amazing work that was done to my neck and how lucky I was to find Dr. Bertagnoli.

Hey Tim -- I just wanted to let you know that I did receive the revised invoice from ProSpine a few days after your email. I immediately submitted the invoice to BCBS and guess, what? A week later we received a check in the mail from BCBS for $54k!

I thought you might be interested to know that BCBS did pay our claim, as it might benefit some of Dr. B's other U.S. patients. If you are interested, I am happy to share with you the demand letter I submitted to BCBS addressing their position that the multi-level ADR is excluded as "experimental or investigational." I had actually filed a lawsuit against them last week, which will be dismissed now that they have paid the claim. It doesn't appear that they paid as a result of the suit, because they hadn't received notice of it on the date they issued the check. It may be that they intended to pay it all along, but were waiting for the revised invoice. At any rate, Liv and I wanted to send our most sincere thanks for your assistance.

Most important, Liv continues to improve and is doing well after her 3 level cervical ADR. You can add us to the growing list of satisfied ProSpine customers!

Best regards,
John Hyatt
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