5 Tips to Appeal an Insurance Denial for Spine Surgery

What do you do if coverage for your spine surgery is denied by your insurance provider? Sometimes, the denial may be an indicator that you truly do not need the surgery.

Watch: Video: Am I a Candidate for Back Surgery?

On the other hand, if you and your surgeon are certain that surgery is the best option, you will need to submit an appeal to your insurance provider.

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For a small percentage of patients, surgery may be the right option to treat pain caused by a degenerated disc.
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North American Spine Society offers guidelines to appeal an insurance company denial

The North American Spine Society (NASS) has made the appeals process a little easier for you by publishing treatment guidelines for different spine surgery procedures (with plans to write guidelines for 17 more). These guidelines were written to define when surgery is and is not recommended.

I spoke with Eric Muehlbauer, Executive Director of NASS, about how to navigate the insurance appeals process if a patient is denied coverage for a spine surgery. He suggested following these 5 tips to improve your chances of having a successful appeal.

5 tips for a strong appeal

  1. Work as a team with your surgeon.

    Your case will be stronger if you and your surgeon are able to work together as a team to present your case to the insurance companies in the strongest light possible. Your physician will be able to help you collect all the evidence you will need as you move forward with the appeals process.

  2. See Preparing to Meet with a Spine Surgeon or Spine Specialist

  3. Follow the established appeals process.

    As part of the 2010 Affordable Care Act, every insurance provider, including Medicare, is required to have an appeals process in place. If you are denied a medical procedure or a prescription, you have the right to ask for a reconsideration of the decision.

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  1. Ask your surgeon to call the medical director who handles spine cases.

    Nothing is more effective than a personal phone call, giving your surgeon the opportunity to describe the urgency of your case to the spine cases medical director at the insurance company. Having NASS’ guidelines for your particular case to share with the director will be especially helpful, serving as a third-party endorsement.

  2. See Present Back Problems to the Spine Specialist or Spine Surgeon

  3. Build a rapport with your contacts at the insurance company.

    As you and your surgeon communicate to your insurance provider, whether through emails, phone calls, or letters, work to establish a rapport with your contacts there. Talk to your contacts at the company as you would a client or business associate, keeping the tone professional. Keep in mind that the more level headed, calm, and educated you are about your condition, the more likely it is your case will be taken seriously.

  1. Provide evidence.

    The more evidence you provide, the better your chances of winning the appeal. This is where NASS’ published guidelines may be helpful. Have medical records ready to show your complete medical history. Also compile a list of the nonsurgical treatments you’ve tried. Prepare a written statement of how your spine problem has affected your ability to work and lead a normal life.

    See When to See a Surgeon for Low Back Pain

We know how frustrating it can be dealing with insurance companies, especially when you are in pain. We hope these tips will help make the process a little easier, and we thank NASS for advocating for patients and doctors by developing these important guidelines.

Learn more:

Getting a Referral to a Spine Surgeon

Specific Questions to Ask Your Spine Surgeon

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