Frustrated with BCBS! HELP!

[manderson33]

I have just received word Anthem BCBS has denied my surgery scheduled for Nov. 1st. I was scheduled for a lumbar fusion L4, L5;L5, S1, because "I have no slippage (spondylolisthesis) or spinal instability." and "There is no record of severe narrowing where the nerves exit the spine." They do acknowledge a herniated disc and that I have back pain. I have been diagnosed with severe DDD and had a laminectomy for the same levels in '06, but re-herniated 5 months later. My surgeon at the time recommended another surgery and possible fusion, but I was not convinced surgery was the answer and wanted to try anything and everything to avoid it. Since then I have been living in pain, having to take pain meds, exhausted other treatments including chiropractic, epidurals, cortizone shots, etc. Finally getting to a point where I couldn't take it anymore, I sought the opinion of a surgeon recommended by my pain management doctor. This surgeon, who is considered conservative, has recommended lumbar fusion of both levels after receiving the results of my recent discogram and thinks the results could be quite favorable, giving me hope of living a normal life free of pain. Having heard BCBS has denied my only hope of getting better is devastating to say the least. My provider has already started the appeals process and has requested a peer to peer review. It was suggested to me that I withhold my appeal until a determination is made on the provider's appeal. Any help or suggestions are greatly appreciated. I have read some of the other insurance posts and have found comfort in knowing I am not alone, but I am wondering if any of your determinations were reversed and if so, what additional info. helped? I'd also like to know what kind of time frame your appeal process took? Thank you!

[Dc_indi]

Did you have any luck fighting BCBS?

I recently was denied and would appreciate any assistance in appealing. Thank you.

[jsewell]

Hi someone is dropping the ball if your surgery was just denied the night before. You did not mention what it was for either. But i have had 10 spinal surgeries in the last 5 years and a lot of them are denied at first. Some times the doctors office does not send in a reqired piece of info. Did you get the reason why it was denied? ONce it was an x-ray for me that the insurance co had wanted. I had broken my neck and needed an extensive reconstructive surgery and i knew they couldn't just leave me like that so i went to the doctors office and called my insurance co and talked to both of them. I asked for them to just give me the darn x-ray and i would do the hour drive to the insurance co to deliver it. Suddenly everything went smoothly and the decision was reversed. Most of the times my surgeon must have a peer to peer review with the insurance co doc and that is when the decision is reversed. so far, knock on wood, they have always been overturned.
I have had one time it was cancelled as the surgeon decided we had a surgeon better equipped in the city to do my case so i understand the disappointment of having it all ready in your mind only to delay it by a lot. Good luck and make sure you post any more questions and let us know the good news when it is approved.
judy

[mmglobal]

DC_indie, welcome to the forum! Note that the thread you found was posted a few years ago by someone with only a couple of posts. I doubt manderson will see it. You might want to try sending a private message or email to them directly. If you do find him or her, ask if they'll post an update here.

All the best,

Mark