Blue Cross Denied Fusion - Help Needed

[manderson33]

I have just been denied fusion by Anthem BCBS, levels L4 L5, and L5 S1, citing "not medically necessary" because of failure to prove instability. I had a laminectomy in '06 for the same levels. 5 months later I had a re-herniation at L4, L5. I have been diagnosed with severe DDD by at least 4 doctors and have exhausted every other non-surgical treatment since my first surgery including epidurals, PT, cortizone injections, etc. After living in pain for the last 4 years and having to take more and more pain meds., I decided to seek yet another opinion from a so called "conservative" surgeon. Even he believes a fusion could help me live a normal life--there was a good chance I could be the wife and mother I so wanted to be. My surgery was scheduled for Nov. 1 but yesterday I received word that the surgery has been denied by BCBS. I am extremely frustrated and depressed. My doctor's office is beginning the appeal process and plans to do a peer to peer review. The insurance broker from my husband's place of employment is looking into the matter as well. Someone had suggested I not appeal until a decision has been made with the doctor's appeal. Any suggestions from anyone would be greatly appreciated.

[gwin]

One suggestion, and that is to find out EXACTLY what procedures and billing codes were submitted to Blue Cross by your doctor. In my case, after losing my appeal, I found out that the doctor's report had the level to be fused as L3 and L4, rather than L1 an L2. None of this will be found in your denial from Blue Cross, because they don't want to you know. Check everything submitted for errors.
I am going to have my doctor re-submit the fusion request based on incorrect information submitted the first time, but have been warned I will still most likely be denied, even though I like you fit the perfect profile for fusion. I would also suggest getting Laurie Todd's book "the Insurance Warier" and start preparing on appeal. Best of luck, and please let us know the outcome.

[mmglobal]

A client of mine had a 3-level lumbar fusion denied in July, just 2 days prior to surgery. It was somewhat surprising, because his DDD is so severe, most surgeons would feel very justified in doing such a surgery.

The surgeons are telling us that the insurance companies are emboldened to deny more and more surgeries, based on the "same outcomes 2 years out" studies. It's really a shame, because in many cases, fusion really represents the patients' best option.

However, in this case, we are saying that he is VERY LUCKY to have the denial. Further investigation determined that his major pain generator was a sacral tarlov cyst. Clearly, the fusion would not have addressed the problem that they were trying to solve or improve. (I don't know if I've ever had the occasion to uttered a prase like, "boy are you lucky the insurance company denied your surgery!")

As the insurance companies continue to raise rates, cut remibursement levels, cut services and increase profits; things will get worse. Whatever your politics on healthcare reform, it's hard to imagine things getting better with or without the pending reforms.

Mark

[gwin]

Mark:

Was the company that denied the fusion Blue Cross?

[mmglobal]

Yes... the blues seem to be great at some things, but in terms of denying surgeries are becoming one of the worst.

[tatianak2]

I am a 35 year old female with a 2 1/2 year old daughter. I currently pay Anthem Blue Cross $666 per month for my medical insurance premium for me alone. Anthem Blue Cross denying me a procedure 6 Orthopaedic Surgeons say I need. Anthem\'s employeed physician says it\'s \"Not Medically Necessary\".
Over the past 3 1/2 years I\'ve had really bad lower back pain and sciatica running down my entire buttocks and left leg to foot. I\'ve tried all conservative methods the doctors gave as a course of treatment, anti-inflammatory medications, pain medications, physical therapy, acupuncture, injections, chiro, light exercise, massage, etc. All of which either provided very little to no help. The pain has moved into my right leg recently so doctors ordered 2nd MRI which showed completely degenerated disc and bulge and doctors say spinal fusion at L5 S1. 2 days before the surgery...Anthem Blue Cross paid physician \"Dr. Marappa Gopinath\" denies the authorization stating not medically necessary based on a Milliman Care Guide. Also my Surgeon put in multiple requests for a Peer to Peer (what physicians will often do so they can help the Anthem Physician understand your injury or problem). Their \"Dr.\" never returned my doctors call and did not honor the peer to peer. After sending over records from other physicians which supported the surgery, Anthem \"Dr.\" still denied the authorization. I\'m only 35...how can Anthem be allowed to force me to be in pain for the rest of my life or go bankrupt trying to finance this procedure on my own. How do I take care of my 2 1/2 year old daughter with this back pain and sleep deprived from the pain. Is this legal? Is this humane? Is this what average income Americans should expect moving forward in terms of quality of life and Healthcare?

Has anybody talked to an Attorney?

Please Help

[mmglobal]

tatianak2,

Welcome... I'm sorry about your situation. I've been doing this for nealy 10 years and know literally hundreds of ADR patients. A few get it covered, but sadly, most self pay. I've had clients who are high powered lawyers and doctors. Not all of them get it covered, but from their position of power, more of them are successful. It frustrates me to see people to whom the money means nothing, get it covered; while those who spend thier savings future retirement income on the surgery, must self-pay.

If you contact me off the forum, I can send you some successful appeal docs. I'm still in Europe now, but will be home mid-week.

Good luck! All the best,

Mark

[Trinald69]

I was to denied for a back fusion L4 and L5s1 the first 3 times they said there was no evidence of degenerative disc disease and I needed to do physical therapy and pain management
Did that then had another MRI and proved that I had what they said I did not have and they came back with my back was not unstable !
Funny we proved what they said I did not have then they came back with the unstable answer and sent me policy's that the fusion surgery was Investigational and is not medically necessary prov en to work! I had two Peer to Peer doctor calls with Blue Cross and they still gave denial for surgery oh and bye the way that was two different surgeons request from two different States!
Once the doctor proved that I had degenerative disc disease they gave a new reason to Deni the surgery

I don't think Blue Cross want's to pay anything for anyone!!!!

Originally Posted by manderson33

I have just been denied fusion by Anthem BCBS, levels L4 L5, and L5 S1, citing "not medically necessary" because of failure to prove instability. I had a laminectomy in '06 for the same levels. 5 months later I had a re-herniation at L4, L5. I have been diagnosed with severe DDD by at least 4 doctors and have exhausted every other non-surgical treatment since my first surgery including epidurals, PT, cortizone injections, etc. After living in pain for the last 4 years and having to take more and more pain meds., I decided to seek yet another opinion from a so called "conservative" surgeon. Even he believes a fusion could help me live a normal life--there was a good chance I could be the wife and mother I so wanted to be. My surgery was scheduled for Nov. 1 but yesterday I received word that the surgery has been denied by BCBS. I am extremely frustrated and depressed. My doctor's office is beginning the appeal process and plans to do a peer to peer review. The insurance broker from my husband's place of employment is looking into the matter as well. Someone had suggested I not appeal until a decision has been made with the doctor's appeal. Any suggestions from anyone would be greatly appreciated.

[mmglobal]

Welcome to the future. Surgeries can fail, so they'll deny them all. Our laws are written by our politicians for their constituents. The constituents are the insurance companies, oil companies, banks, etc… It will only get worse as decisions like “citizens united” will allow even more corporate money to drown out voices of the people. How sad.

[Maria]

I saw my OSS he said "I can't do anything for you, come back in 6 months" because I was there requesting an ESI to be ordered and then hopefully authorized. He said "forget it, WC isn't going to pay for anything anymore."

It's a manipulative move for WC to get me to settle out my future medical and have me go to Medicare Set Aside. He then said that Medicare wasn't going to pay for any surgery w/i a few years as well. Then he said "that's ObamaCare." Haven't been back to see him for 10 months. If I really "need to" I'll go though for now self managment and pain med seems to work. I had hoped to get off pain medication one day though at least can function fairly well on it so guess I'll be happy for that much. Used to be my OSS thought get off pain med and so did WC. Last few times I saw him he said if I could function well on it and not have much pain don't do anything surgically. Agreed. WC must like that it's a super cheap pain med. Has to be the cheapest on the market.

I agree w/get rid of HMO's. When working for one most of what I saw was a very few good medical practitioners pushing things through and being as thorough as I thought they should have been in diagnostics and treatment. Saw some really bad stuff. Saw a bunch of stuff that would get "hidden" or changed if attorneys involved.

Worked in nursing/medicine from when I was in my early 20's and really thought the good old days were much better re doctors being able to practice medicine instead of insurance companies in charge of decision making.

Very sad. Agree we need a big huge overhaul of our system as too many people don't have $ to pay to go elsewhere and shouldn't have to in order to get medical needs met. We're supposed to be healthy enough to be productive and work or at least function doing ADL's but can't get the adequate or appropriate care to make that happen esp. with ridculously high deductibles/copays/cobras and such??? Disgusting to say the least.