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Insurance Issues Discuss Blue Cross Denied Fusion - Help Needed in the Main forums forums; Hi Tatianak2 and welcome to the forum, When I read posts like yours it makes my blood boil. You're ...

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  #11 (permalink)  
Old 12-19-2010, 09:38 PM
dshobbies's Avatar
Senior Member
Join Date: Oct 2006
Location: Los Angeles
Posts: 1,596

Hi Tatianak2 and welcome to the forum,

When I read posts like yours it makes my blood boil. You're doing everything right - yet they have refused the peer to peer. Have you spoken to anyone or is this all through letters because I'm sure they can claim they never recieved the requests.

My first suggestion is to talk to someone instead of letter writing. Make sure they get these requests. You can always get the insurance commission involved over their lack of responce. You can threaten legal interference as well as actually getting a lawyer but I'd try the others first. And despite the time of year, there's nothing like right now.

Having said all that, I am so sorry for your suffering. No you shouldn't have to live in pain or go bankrupt for a surgery they do cover. Not medically necessary MY ASS (excuse my language).

3 level Prodisc adr S1-L3, Oct 12, 2005
Dr. B in Bogen, Germany
Severe nerve damage in left leg, still working on it
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  #12 (permalink)  
Old 01-01-2011, 02:06 PM
Senior Member
Join Date: Dec 2010
Location: oklahoma city ok usa
Posts: 195
Default I had Blue Cross Blue Shield

They paid for my first two surgeries. It depends on the type of policy/coverage I can only suppose. I was under a group policy. I am on a different insur now with my husbands. I was afraid that if I did not change when I had the chance, something would happen and if I lost my job I would not have insur.
female age 45, height 5"6", 145 lbds, non smoker, conservative treatments failed, (7/2007) C4/5/6 peek disc replacements,plate & screws failed fusion,
(9/2008) revision with bone replace plate and screws, (10/2009) C3/4 stand alone peek cage, (12/2010) facet joint injections C3-7, (1/2011) rhizotomy C6/7 failed, Trouble swallowing
most recent mri (7/2011) shows ajacent level issues: right neural foraminal narrowing C2/3, posterior bulge indents thecal sac at C6/7/T1 no mass effect on cord.
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  #13 (permalink)  
Old 01-03-2011, 05:34 PM
Junior Member
Join Date: Jan 2011
Posts: 1
Default Grass Roots Battle

I am a spine surgeon and sit on committees of NASS, ACSS, ABOS. We have sent a letter to BCBS of NC challenging this.

Welcome to the beginning of Obamacare. I am NOT sensationalizing things. It is the absolute intent to ratchet down covered care in all aspects of medicine. Not just end-of-life (which is currently being targeted), but procedures that children and young adults get that would help them live the rest of their lives more productively with better quality.

The standard that they are setting is LEVEL I (one) studies. That means studies that are prospective and blinded. There are very few treatments in medicine that can meet this scrutiny. Therefore, they simply get to pick what they want to attack next, get a committee to justify why there is no Level I evidence to support, and then write a policy of non-coverage.

The only way this is going to be stopped is for every citizen to fight it. We need to fight it by challenging our insurance companies, by writing to our state and federal legislators and by voting in upcoming elections. If we do not turn this around, in 5 - 10 years we will have one of the worse medical systems in the world. The time to act is now and we must attack at every angle. Get involved, write letters, get friends involved and VOTE.

"YES WE CAN" have the best healthcare system in the world, but we ALL are going to have to fight for it.

LINK to Reply: NASS and Multi-Society Coalition Submit Comments on NC BCBS Lumbar Spine Fusion Policy

Last edited by pnunley; 01-03-2011 at 05:44 PM. Reason: added link
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  #14 (permalink)  
Old 01-05-2011, 12:15 AM
dshobbies's Avatar
Senior Member
Join Date: Oct 2006
Location: Los Angeles
Posts: 1,596

Dr. P,

I agree with you but there is a huge problem with our current system. Aside from the only people making any money are the ins co, my self employed husband and I were paying $1800 per month for health covereage (PPO). We couldn't afford it anymore and switched to $1200 very high deductible policy, also PPO. HMO's weren't any cheaper, but had less deduct/copays. If we couldn't get a small group policy I'm basically uninsurable because of my history.

We both turn 60 this year and the high deductible policy is going back up to $1800.

My son can't even afford food and has no coverage at all. Another son's wife has coverage from work but they recently cancelled all spousal ins. He had to get his own policy. Work is decreasing their contribution so they're paying much more for less coverage. 3rd son also must pay higher % of premium.

The idea that anyone has the right to tell me or my doctor what they will or will not allow for medical treatments is a bad one. I don't think anyone disagrees with that statement. The rich will live, the poor will suffer. But $1800 per month is a mortgage payment. The system wasn't broken until HMOs entered the game. Why not simply outlaw any managed system and we'll go back to the way it was????????

Business is bad (big wow there) and we simply cannot afford this anymore. If one of us is hospitalized or needs surgery- ouch! Something has to change.

3 level Prodisc adr S1-L3, Oct 12, 2005
Dr. B in Bogen, Germany
Severe nerve damage in left leg, still working on it
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  #15 (permalink)  
Old 01-08-2011, 01:45 AM
Junior Member
Join Date: Aug 2010
Posts: 9

DSHOBBIES, you are exactly correct about health care going down the tubes when HMOs came on the scene! I'm a retired R.N., graduating in 1965, so I've seen the changes in the insurance industry since HMOs became "popular." And, of course, they started in California! I worked with a nurse anesthesist who worked at Kaiser Permente, which was the first HMO. Dr. P is right, we've got to keep the heat up on our legislators as obamacare will destroy our health care system, which has been the best in the world. Breaks my heart to read these posts about denials. Workers' Comp carriers are just as bad. They find quacks who'll report in favor of the insurance company, and that caused my DHs lumbar fusion to be delayed for ONE YEAR! He was in such pain that he rarely was able to leave the house. Praise God, he was fused on Dec 1st, using the Medtronic CD Quadrant Sextant System, and is doing just great! Even better than his neurosurgeon expected, this soon post-op.
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  #16 (permalink)  
Old 02-04-2011, 03:25 AM
Senior Member
Join Date: Jun 2010
Location: Sierra Madre, California
Posts: 904

My orthopedists office will not book surgeries until they have the approval code in their hand.

for my last surgery of Jan7th. My head was on my chin with x-rays showing a 90 degree turn at the top of my thoracic spine and I had equipment sticking out of my back from my recent thoracic/lumbar fusion/osteotomy. Not to mention the pain getting worse every day. I just stayed in bed toward the end it was too painful just to walk and i know i looked weird as i could not put my head up.
Well the surgery was denied by Blue Cross of Ca. The doctors office was right on it and the peer to peer happened within days. I was told it was going to be approved probably the next day. Well i faced 2 more denials,of not neccessary.
I was lucky the assistant at my surgeons office was so confused with all my paperwork as i had 3 surgeries in a row that she set up the date of Jan 7th.
Once i got really involved i realized my spine docs office had never sent the xray. So i went to his office to get the Ctand MRI , i already had the xray as it was so unbelievable, got all the reports and told them i was driving the 2 hours to Blue Cross to deliver it as they never got the xrays there.
Well then the office person asked where i got the xray. I told her everything came from their office and if they could email it all i did not havea to make the drive. My poor doc had 2 other peer to peers also and it finally got approved, but 3 denials first.
All for an error. also Blue Cross told me there was a coding error as well. I can't believe they would not just fix it instead of keeping it a secret as to what is wrong.
To save my date i had told them i would self pay . My doctor assured me no surgeon could deny this after seeing the xray. They just wanted someone other than him to say what was going on. So i was not afraid to put my self out on a limb but really would have to get the money from my parents.
Good luck and let me know if you need a body to join you at Blue Cross office.
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  #17 (permalink)  
Old 03-23-2011, 10:02 PM
Junior Member
Join Date: Mar 2011
Posts: 1

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 View Post
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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  #18 (permalink)  
Old 03-24-2011, 07:29 AM
mmglobal's Avatar
Join Date: Sep 2006
Posts: 2,508

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.
1997 MVA
2000 L4-5 Microdiscectomy/laminotomy
2001 L5-S1 Micro-d/lami
2002 L4-S1 Charite' ADR - SUCCESS!
2009 C3-C4, C5-C6-C7, T1-T2 ProDisc-C Nova
Summer 2009, more bad thoracic discs!
Life After Surgery Website
President: Global Patient Network, Inc.
Founder: www.iSpine.org
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  #19 (permalink)  
Old 03-28-2011, 05:26 PM
Senior Member
Join Date: Sep 2006
Posts: 2,405
Default last time

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.

Last edited by Maria; 03-28-2011 at 05:32 PM.
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  #20 (permalink)  
Old 07-19-2011, 02:31 PM
Junior Member
Join Date: Jul 2011
Location: rural Ohio
Posts: 1
Unhappy Level 2 appeal today, not much hope for approval

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.
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