Go Back   ISPINE.ORG Forum > Main forums > Insurance Issues
Register FAQ Members List Calendar Search Today's Posts Mark Forums Read

Insurance Issues Discuss Blue Cross Denied Fusion - Help Needed in the Main forums forums; I was set for a 2 level bi-lateral decompression and fusion of L1,2 and L2,3 plus laminectomy ...

View Poll Results: Has anyone been approved by Blue Cross for a back fusion with:
No spinal instability 0 0%
Pain only 0 0%
Multiple Choice Poll. Voters: 0. You may not vote on this poll

Reply
 
LinkBack Thread Tools Display Modes
  #1 (permalink)  
Old 07-05-2010, 12:19 AM
Junior Member
 
Join Date: Feb 2010
Posts: 4
Default Blue Cross Denied Fusion - Help Needed

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.
Reply With Quote
  #2 (permalink)  
Old 07-05-2010, 04:14 PM
dshobbies's Avatar
Senior Member
 
Join Date: Oct 2006
Location: Los Angeles
Posts: 1,597
Default

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
__________________
3 level Prodisc adr S1-L3, Oct 12, 2005
Dr. B in Bogen, Germany
Severe nerve damage in left leg, still working on it
Reply With Quote
  #3 (permalink)  
Old 07-06-2010, 12:18 AM
Junior Member
 
Join Date: Feb 2010
Posts: 4
Default

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
Reply With Quote
  #4 (permalink)  
Old 10-19-2010, 08:44 PM
Junior Member
 
Join Date: Oct 2010
Posts: 2
Default

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.
Reply With Quote
  #5 (permalink)  
Old 10-19-2010, 10:43 PM
Junior Member
 
Join Date: Feb 2010
Posts: 4
Default

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.
Reply With Quote
  #6 (permalink)  
Old 10-20-2010, 07:23 PM
mmglobal's Avatar
Administrator
 
Join Date: Sep 2006
Posts: 2,487
Default Another fusion denial

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
__________________
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
Reply With Quote
  #7 (permalink)  
Old 10-20-2010, 08:27 PM
Junior Member
 
Join Date: Feb 2010
Posts: 4
Default

Mark:

Was the company that denied the fusion Blue Cross?
Reply With Quote
  #8 (permalink)  
Old 10-21-2010, 08:15 PM
mmglobal's Avatar
Administrator
 
Join Date: Sep 2006
Posts: 2,487
Default

Yes... the blues seem to be great at some things, but in terms of denying surgeries are becoming one of the worst.
__________________
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
Reply With Quote
  #9 (permalink)  
Old 12-19-2010, 04:18 AM
Junior Member
 
Join Date: Dec 2010
Location: Redondo Beach
Posts: 1
Unhappy Denied By Blue Cross as Well!

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
Reply With Quote
  #10 (permalink)  
Old 12-19-2010, 01:47 PM
mmglobal's Avatar
Administrator
 
Join Date: Sep 2006
Posts: 2,487
Default

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
__________________
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
Reply With Quote
Reply

Bookmarks

Thread Tools
Display Modes

Posting Rules
You may not post new threads
You may not post replies
You may not post attachments
You may not edit your posts

BB code is On
Smilies are On
[IMG] code is On
HTML code is Off
Trackbacks are On
Pingbacks are On
Refbacks are On



All times are GMT. The time now is 02:57 AM.


Powered by vBulletin® Version 3.7.2
Copyright ©2000 - 2014, Jelsoft Enterprises Ltd.