Blue Cross Denied Fusion - Help Needed

[colomom]

My teen daughter ruptured L4-5 and L5-S1 last year, and after months of PT and 3 unsuccessful rounds of spinal injections, she received a two-level discectomy, which was paid for by CIGNA. Ten months later, she started having the radiating leg pain again, and the MRI indicated a reherniation of both levels. She was unable to sit in school for longer than 10 minutes (she missed her first semester of her sophomore year last year in bed because of the same pain), and we were scheduled for surgery including the fusion of the L4-5 because the expectation is that repeating the prior procedure would net the same result. The goal was to stabilize the spine before further injury occurred and prevent a third herniation, but we were denied coverage for not attempting other non-surgical treatment, as well as not meeting the instability requirement. After almost a month of waiting (and denials), we ended up proceeding with the recommended procedure and self-paid. We could not afford for our daughter to miss another semester of school waiting for an approval that may never come. I am currently appealing, but not hopeful. It's horrific to think that we have to wait until so much irreversible damage is done before care will be provided, when we could proactively maintain the health of the spine before then and possibly prevent further surgeries and unnecessary (and costly) non-surgical treatments. My daughter is only 16, and is currently living the life of a normal, happy teenager after surgery 7 weeks ago.

[dshobbies]

Hi C and welcome to the forum,

First, we've heard this story before. Stay after them but first, find out how their specific appeals process works. It would also help if you have a doctor in your corner willing to do battle with these sobs, saying that nothing less would have helped ease her pain, only prolong it.

Mark has a book in his library about the health insurance appeals process. It would help in drafting your appeals.

Lastly and I hate to say this, but if all else fails, sue the crap out of these people. (sorry to be so blunt) They won't cover ADRs because fusion is the main stream but they won't cover that either BS.

Good luck, Dale