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

[gwin]

Mark:

Was the company that denied the fusion Blue Cross?

[mmglobal]

Yes... the blues seem to be great at some things, but in terms of denying surgeries are becoming one of the worst.

[tatianak2]

I am a 35 year old female with a 2 1/2 year old daughter. I currently pay Anthem Blue Cross $666 per month for my medical insurance premium for me alone. Anthem Blue Cross denying me a procedure 6 Orthopaedic Surgeons say I need. Anthem\'s employeed physician says it\'s \"Not Medically Necessary\".
Over the past 3 1/2 years I\'ve had really bad lower back pain and sciatica running down my entire buttocks and left leg to foot. I\'ve tried all conservative methods the doctors gave as a course of treatment, anti-inflammatory medications, pain medications, physical therapy, acupuncture, injections, chiro, light exercise, massage, etc. All of which either provided very little to no help. The pain has moved into my right leg recently so doctors ordered 2nd MRI which showed completely degenerated disc and bulge and doctors say spinal fusion at L5 S1. 2 days before the surgery...Anthem Blue Cross paid physician \"Dr. Marappa Gopinath\" denies the authorization stating not medically necessary based on a Milliman Care Guide. Also my Surgeon put in multiple requests for a Peer to Peer (what physicians will often do so they can help the Anthem Physician understand your injury or problem). Their \"Dr.\" never returned my doctors call and did not honor the peer to peer. After sending over records from other physicians which supported the surgery, Anthem \"Dr.\" still denied the authorization. I\'m only 35...how can Anthem be allowed to force me to be in pain for the rest of my life or go bankrupt trying to finance this procedure on my own. How do I take care of my 2 1/2 year old daughter with this back pain and sleep deprived from the pain. Is this legal? Is this humane? Is this what average income Americans should expect moving forward in terms of quality of life and Healthcare?

Has anybody talked to an Attorney?

Please Help

[mmglobal]

tatianak2,

Welcome... I'm sorry about your situation. I've been doing this for nealy 10 years and know literally hundreds of ADR patients. A few get it covered, but sadly, most self pay. I've had clients who are high powered lawyers and doctors. Not all of them get it covered, but from their position of power, more of them are successful. It frustrates me to see people to whom the money means nothing, get it covered; while those who spend thier savings future retirement income on the surgery, must self-pay.

If you contact me off the forum, I can send you some successful appeal docs. I'm still in Europe now, but will be home mid-week.

Good luck! All the best,

Mark

[dshobbies]

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).

Dale

[cherylstewart67]

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.

[pnunley]

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

[dshobbies]

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.

Dale

[AnnOdom]

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.

[jsewell]

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.
judy

[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.

[Maria]

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.

[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??

[Guido]

Mark,
Where can we find reviews or other info on orthopedic surgeons? I'm in Northern Cal and with Kaiser.
Thanks!

[mmglobal]

Guido, there isn't any place that I know of that has the information you seek. My experience is that a small number of internet vocal reviewers will dominate the reviews and that type of anecdotal information is of little value. Most states have websites available on which you can find information on lawsuits against the doctors and a lot of lawsuits are a bad sign, unless the surgeon helps develop or is an early adopter of new technology.... this makes him or her an easy target so the lawsuit data doe not provide an accurate representation of the doctors skills or abilities.

Good luck... let us know if you find anything useful.

Mark