[Maria]

Randy,
I think you have to wait until you see the Neurosurgeon as a first consult as they've not denied you a consultation with a spine specialist they've just denied one with an orthopedic spine specialist.

After you've seen the first consult generally 2nd surgical opinions are obtained only if surgery is recommended.

I'm pretty sure when there is no specialist within the network if one is in need of a 2nd surgical opinion they can be granted an appt. with an out of network physician but when it's a "2nd opinion" only I think you have to check with membership services.

There are policy and procedure manuals that should have this all outlined and I don't know if you'd be fortunate enough to get a truly honest person that would send you a copy of whatever policy that would state their 2nd opinion policy however that's probably what you're going to have to look into at some point should you want a 2nd opinion that you aren't going to pay out of pocket.

I think first it would be prudent to go to the consult with the Neurosurgeon you've been given and see what this person has to say. Neurosurgeons are generally more conservative than Orthopedic surgeons from my experience however it would depend on your specific findings. Also HMOs seem to be very conservative when it comes to authorizing surgery but I think if someone's MRI screams "surgery is necessary" then surgery would be authorized .

It's just often in the case of low back problems that are painful but not creating problems like neurodefecits or something that necessitates surgery then surgery is not recommended and usually conservative care is the starting point. This means a trial of PT, first line meds like Nsaids, muscle relaxers, and possibly meds for neuropathies. If someone tries these meds and they don't work probably a referral to Pain Management is in order and there one might be offered various injections and stronger meds for pain.

I think you've been thru a trial of some of the meds so you can say what has and hasn't worked for you.

Anyway back to the point I think you'll have to see the referral you were given first before you can make an appeal because as far as the HMO is concerned they are giving you a referral to a spine specialist in Network just not an OSS.

The HMO I worked for was under the United HealthCare umbrella but I stopped working there in 2000 so most likely some things have changed with regard to policies. I doubt policies have changed drastically with regard to 2nd surgical opinions however it might just be that you are looking for a 2nd opinion vs. 2nd surgical opinion depending on what your consulting Neurosurgeon has to say.

Make sure going into the appt. you have some questions formulated and written down because you may or may not get someone that is willing to explain things to you.