Blue Cross Denied Fusion - Help Needed

[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.