Long post but similar to your experience. I have considered the CA-DREZ carefully as it is a very invasive procedure, a last resort at this time and I am ready for it if the evaluation shows promise.
I have been following your posts on the DREZ as it seems I could be writing it. I was injured in 1976 at age 34, yep I am 69 right now. My level is T10 - Ll, Harrington Rods which fracture and were removed in 2008. I have been with the same Medicare Advantage provider (Secure Horizons) and the same Medical Group since 1989. A referral for a DREZ evaluation from my pain management group was submitted to my medical group in January 2010 which was approved. After seeing two neurosuregenon I still did not have the evaluation, but both recommended that I look into Computer Assisted DREZ as done by Dr. Falci at Craig. The group approved the evaluation but insisted they could do it in group. I was then sent to UCLA and UCSF, neither one would make an appointment for DREZ or CA-DREZ. I appealed to Secure Horizons for the evaluation at Craig, denied because it can be done in California. I go to the next level of appeal with MAXIMUS, they agree with Secure Horizons that it can be done in California. I send MAXIMUS the information about UCLA and UCSF and they reopen the appeal. Dr. Falci’s office tells me they accept Medicare for the CA-DREZ, I am about to send the information to MAXIMUS when I receive a letter from them, August 30, 2011 (attached). Up to this time all the denials have been because the procedure could be done within the Secure Horizons network in California, now the reason is because the CA-DREZ is not a covered benefit. The doctor review from MAXIMUS is a bit ambiguous, it seems that CA-DREZ is out but DREZ is in. It will be interesting to see where Secure Horizons will send me next as they have been unable to get me a CA-DREZ or a DREZ evaluation up to now. It has taken 20 months sending me around to providers that could not do either evaluation and now they say that CA-DREZ is not even covered! I just love insurance people. The next level of appeal is the Administrative Law Judge (ALJ) hearing. I have been to one of these before and had the decisions of denial for DME Supplies overturned, but not for all Medicare Beneficiaries, just for me and that did not make any sense to me. I am ready at this time to dis-enroll from SH and go back into fee for service Medicare because I believe it will take longer than the end of the year to resolve this. You would think that if Dr. Falci is getting paid by Medicare for the procedure it would stand to reason SH would have to cover it per 42 CRF 422.101 that basically says that the health plan must pay for a service or item if regular Medicare would pay it.
Question for Garyis - are you a Medicare beneficiary?