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!!!!
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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.
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