Blue Cross Denied Fusion - Help Needed

[gwin]

I was set for a 2 level bi-lateral decompression and fusion of L1,2 and L2,3 plus laminectomy of L3 and L4, but the evening before surgery was notified by my doctors office that Anthem Blue Cross of CA had denied coverage. I have just lost my last appeal. "Not medically necessary" because there in no clear indication of "spinal instability". 24/7 severe pain from L1,2 and L2,3, bone on bone.

I am still trying to fight this, but I need to find other people that Blue Cross has approved for fusion that either had no documented spinal instability or severe pain alone was reason for approval of fusion. Please respond to forum. I would really appreciate anyone who has been approved by blue Cross for fusion feedback. Thanks.

[dshobbies]

Hi Gwin and welcome,

I haven't heard of Blue Cross denying coverage for a fusion, ADR- yes but a fusion, this is a first.

I have two suggestions - there's a book on how to appeal your insurance co - (Mark - help me out here). You can borrow it from Mark's library.

Second, you have the right to ask for a peer to peer appeal, which means your doctor can speak via phone to the same type of doctor, eg neuro-neuro, ortho-ortho, all being back specialists. It's then up to your doctor to convince his couter-part of the necessity of this surgery.

Other than that, insurance companies are in the business of making money. They are not your friend despite the friendliness of whoever you speak to. They pretend they're on your side, Often we must prove our disabilities and even then

In case you can't tell, I hate insurance companies.

Dale

[gwin]

Hi Dale:

Thanks for your comments, I did get and read the book "Insurance Warier: by Laurie Todd. She was very helpful with some suggestions as I was in the process. I though the chances of winning the appeal were good, but it was very rushed as I had to get in my appeal before BC responded or it was all over. Obviously I didn't do as good of job as I should have.

There was a peer to peer doctor's review as soon as I was denied the first time. The word I got then was it was just a paper work problem. Right.

I hope to find some out there soon who were approved for fusion (even if you did not go through with it or got Blue Cross to approve ADR's) that did not have documented "spinal instability" or were approved for pain relief reasons.The guild line that was used against me for the denial was the Blue Cross reference "Millman 13th Edition" Lumbar Fusion acceptance section.

When I pointed out in my appeal that the current Millman is the 14th Edition, and the section for fusion acceptance has been updated to include fusion is their is "anticipated" spinal instability in the event of a bi-lateral decompression, which in my case was one of the things that was going to be done. "Anticipated" is a pretty subjective word and could mean a number of things. Anyway, to me it seems it leave the door wide open for fusion approval in my case, but what happened next left me with no other choice than to believe this whole insurance game is rigged.

I received a call from a representative of Blue Cross informing me that my appeal had been denied. All of it, decompression, even though I informed them at the time of the first denial of service, as did the doctor that due to the degree of compression and the symptoms present I could be an emergency medical situation. I asked her how they could use outdated reference material and ignore what the current version says regarding lumbar fusion.

She stated, and I kid you not, that this issue had been sent out for outside opinion, and when I asked what that opinion was, was told that they had not yet received an answer, but that it should come tomorrow. I then asked how they could deny my appeal if they did not even have an answer to one of my key points. She told me their Medical Officer was "confident" that the differences between the outdated and current Millman manuals would be found to be insignificant. Does anyone else see a problem here?

Gwin

[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

[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.

[chestnutrun]

Today is my first day of joining this network. I can't begin to express my pain, frustration,and exhaustion of dealing witn my denials for a lumbar fusion and laminectomy L3-S1. I have grade1-2 spondylolisthesis, and many other spine complications. I have severe sciatic pain, so lying down, standing & any strenous activities are very painful. I have had a concurring second opinion from another neurosurgeon and still the constant denials. I am in a degenerative state and unless there is some stabilization, permanent damage. I know many of you have been through this or as I am in the process. Can you give me any suggestions or encouragement? I'm pretty depressed right now and this all has defined my daily activities and my life. I know your frustration and pain.

[dshobbies]

Hi Chestnutrun,

Welcome to the forum. We hear you, we know what you're going through and many of us have walked in your shoes. You are not alone.

First, you are entitled to an appeal and I suggest you do so. Mark has a book in his library that can help you draft your appeal. Please contact him at GPN Artificial Disc Replacement ADR.

Also, please start a new thread and tell us about yourself. We're here to help and sympathize, empathize and educate- as well as anything else you might need or want.

I wish you good luck, Dale

[JulieAnnaAK]

I have double health care coverage. Blue Cross is my secondary- they approved both my lumbar and cervical fusions on the first attempt. Incidently my Primary Western Grocers denied both of my fusions.

On the PLIF they also said it was reviewed by their Neuro Surgeon and was not medically necessary. When I asked for the corasponence I discovered that their Neuro Surgeon was not a NS at all. He was a IME! My NS called him and did the peer to peer review and my appeal was approved. Partly I am sure because I called them out on the IME pretending to be a NS.

On the ACDF again Western Grocers took the word of a hired neurologist who performed my nerve conduct study for my NS He was from one of those large spine clinics & said I didn't need surgery just some PT and traction (at his clinic of course). I had to go through 12 more weeks of PT (not his clinic). Traction made me pass out (I had some form of vertebular artery blockage from an island style bone spur than moved with pressure). PT was 2x per week getting a mt. I basically spent 3 months on the couch waiting/miserable.

[dshobbies]

Waiting/miserable - same story, different details. Why ins cos put us all through this. They're disgusting!

[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

[cherylstewart67]

that bcbs and some others are no longer going to cover fusion unless the cord is engaged...they no longer think that it is a fix to issues such as facet joints or ddd...not on tv another forum but it was from a good source

[DreamingAnnie]

I hurt my back 3 yrs ago and have bulging and ruptured discs.I have tried everything to avoid fusion, to no avail...nothing has helped. I saw one chiro 3x week for 1 1/2 yrs. Another chiro for diff type of treatment. A 3rd chiro for 2 months of decompression treatments. I've had 3 epidurals, RF ablation, months of Physical therapy, tried yoga and pilates. I've seen 4 Neurosurgeons in which every one of them said I need Fusion. I finally agreed and was scheduled, denied by insurance( Anthem Blue Cross), Dr attempted for over a month to do a peer to peer. Drs office said they felt they were being ignored, of course they were! When it finally did happen, they still denied surgery but said I had to go through PT first before another request. Did that, didn't help. Surgery was scheduled again,denied, did peer to peer again, denied.Did appeal, denied again.
Said same thing they tell everyone, no spinal instability. And basically that soft tissue(discs) doesn't matter.I have one appeal left. Luckily, my cousin is a lawyer and offered to help me with my final appeal. Has anyone ever actually been able to get their insurance to say yes??