Insurance won't cover lumbar fusion

[Stamar]

Hi all.

I am embroiled in an appeal process with my insurance company because they keep denying my L4/L5 lumbar fusion as "not medically necessary". My neurosurgeon has indicated that I meet every criteria and it was still denied. Has anybody gotten their insurance company to cover this? I have a level 2 appeal tomorrow over the phone. Hence my urgency.

Thank you very much,
stamar

[R2 D2]

I live in kentucky and I'm insured by Anthem. I have been denied the exact same surgery twice now and just sent my letter of appeal minutes ago. I have had three doctors now that agree on my operation. I have been on short term disability for two months now and living in constant pain. I have scheduled an appointment with my doctor tommorow to see what he can do. This is unfair and inhumane. If any of those guys in the corperate offices of Anthem could experince the pain I go through on a daily basis, they would change their tune a little bit about what criteria must be met to cover this procedure.

[jerryjezza]

I know about this pain because my uncle had this pain.
My opinion is that in general, insurance companies have it right regarding lumbar fusion surgery, but they are inconsistent in their policy regarding lumbar fusion surgery for disc related low back pain. They acknowledge the diagnosis exists by allowing artificial disc replacement, but for some reason they do not believe that lumbar fusion is a legitimate option for the same diagnosis.
It would make sense to stick with a tried and true treatment like anterior lumbar fusion for one-level disc related chronic low back pain, and approve new technology such as artificial disc replacement only after it is shown to be superior, not just equal.

[karreymetris]

Are insurance companies really this difficult? I have never even used mine for anything, never been hurting enough until now.

[mmglobal]

Kerry, it is insane. For the first 9 years I did this, we were frustrated because the insurance company would not pay for ADR. Few have been successful... many more for one level procedures, very few for more common multi-level cases. Cervical ADR was adopted quicker, but many companies will not pay for anything if the term ADR is anywhere nearby... even for hybrid surgeries that are one level fusion w/one level ADR.

Lately, they are even more emboldened and are denying more traditional surgeries like fusion.

As long as the politicians continue to write laws beneficial to industry, even when the industry is completely unreasonable (eg: when they literally deny everything and make the doctor's offices go through a very laborious and paper-intensive process, just for ordinary treatments!), we will be powerless to fight the nonsense. Actually some will fight and win... many, many more will fight and lose; and most won't be able to fight the system. How sad. IMHO, anyone who thinks that the status quo for our medical system is acceptable and reasonable is not well informed about the egregious abuses of the industry.

Having worked for over a thousand spine patients now, I have seen many lives ruined because they don't have insurance, or they have insurance and they deny needed treatments (that all the patient's doctors see as appropriate) and because the patient gets FORCED to accept the wrong treatment because their insurance won't pay for the more appropriate treatment.

We are not talking about wacko experimental procedures. We are talking about something that was FDA approved in 2004!!! They still are allowed to say, 'it's experimental.' That is just BS.

End of rant.

Mark

[jsewell]

My doctor did a good job for me getting some of my denials for surgery approved without me getting involved. Like when my neck was clearly broken and they denied the surgery.
Now my docs (endocrinologists office) had fought with Aetna over a much needed medication for 6 months. I sent in my personal appeal on Jan 10th certified mail and it has been closed as a duplicate 4 times now. Each supervisor says i have the right to file my personal appeal until last friday, now they say it is being squashed because i never had a right to appeal. I just realized i have been fighting them so long i am now eligible to file a whole new request for the very expensive medication. so the new battle will begin.
judy

[Roz]

Hi,

I agree with your comments. Maybe someone out there would help me with a question I am concerned over. I had a one level ADR implanted in Bangkok, Thailand in 2005 at Bumrungrad Hospital. Dr Nanthandej never told me he had no idea how to implant this device ( Pro Disc C C5-6). The implant was placed under sized and is too far ventral and subsiding according to Dr. B in Germany. I sent films to Dr. Demakas in Spokane who was trained I believe by Dr. Ritter- Lang and he agreed. it is auto fused and it has to be removed. I do not want a fusion.

I am now being told that a revision arthroplasty, even with another Pro Disc is not covered. Does anyone know the truth about this.?

[mmglobal]

Roz, a single level fusion is a good surgery with good results. While that is not what we want when we go for ADR, considering the cervical revision and fusion (especially at one level) is so much easier to entertain than lumbar revisions or fusions.

Good luck!

Mark

[jsewell]

I now have a lawyer who works with a foundation sending in an appeal for me for the growth hormone i have been denied for a year. As an adult the growth hormone helps with bone hardening. As a child we all know it provides growth up. I have had so many spinal fractures, do not have osteoperosis and can only point to this hormone , which i am very deficient in. Yet Aetna can't see the big picture.
It was submitted last week, so now they will take their sweet time. The next step is with the state and an independent doctor.
Judy