gwennie---I am so sorry you are going through this-it just %^&*(( me off when I think of someone sitting up in an office somewhere deciding our fate---I am praying for you-love,Jeannie

I wish you the best in your pursuit for getting your surgery approved. Insurance companies are so frustrating to deal with. You are a smart woman and I am sure you gave them a run for their money today. I only had Grade I spondylolisthesis, but it was my horrendous symptoms that swayed my NS to do my fusion. I can't imagine how I would be if my insurance company had denied my surgery just based on a number.

Good Luck,

Marianne

So sorry you had to wait for two weeks just to get frustrated by Ins Co. I know how it feels. I too had the refusal from ins co based on not meeting qualifications. I went through all appeals and prevailed. It was all about going through the external review, and having an disinterested party tell them if the discogram was redone, with recorded pressures, I met qualifications.
So swiftly go through Co appeals, and take it to the state ins comm for external review. They look at things differently than Ins Co do.
Is that a good enough Rah Rah Go Get Em speech for you? I hope so, I want to give you all the hope I can. Take Care, Robin

I think the insurance companies put the bottom line before your health. No brainer there. However, that doesn't make it stink any less! It sure seems like the word of your two trained doctors (who actually laid eyes on you) might outweigh the decisions of a panel of actuaries. I wish you great strength in your fight. Sounds like you're gonna need it.

Aloha,
Aaron

Damn sorry to hear that Gwen. Keep after them, I know you will prevail. You know wayyy to much about the spine and your condition. )

I had a neurologist appointment for early April and got a call that the Neurologist cancelled my appointment saying he cannot help me and that I need to see a neurosurgeon or pain Mgmt Dr.

Today must just be a bad news type of day.... Hang in there.

~BB

Hang in there Gwennie! I am so sorry you have to go through this and I truly know how frustrating it is to have someone behind a desk determine your future!

We are all here to support you! Sending prayers for strength, courage, and patience your way! Hang in there I know you can do this! Shari

hi gwennie
so so sorry your going thru all of this..this is just horrible how can they deny request for surgery they are not medical experts..
how sad you have to wait and go thru this stress
i'm truely sorry..
things have to be done with insurance co.
mine will pay for pt for me to go get u/s massage treatments but will not approve a tens unit..
they will pay up to 3,000 for pt a yr but wont ok a few hundred dollars.
hope you get your apeal won quickly
mary

Hey, not surprised. As others said, it's about making money and they are using actuaralists/statistcs whatever to make 'profit/loss' decisions.

I am glad you are posting to make others aware of how to prepare. I will 2nd the "get a copy of your records". I've been asked 'why?' we have them on line. I tell them, thanks but I never know if I will move and/or if I get hurt the Ambulance won't take me to a hospital that has access to your records and I feel safest if I have a copy.

Typically, you can sign a release to ask for a copy of
- all your doctor appointments doctors notes
- operative notes
- release/discharge notes
- radiology reports and images

It's worth doing.

I have to clean mine up but I have everything from my ER hospitalization back in August up to pre-op of 2nd surgery. I will be sure to get all my information on my recent surgery after I'm cleared for this very reason.

It's a papertrail they hope you won't track.
I treat my medical records like the IRS tax records.

You will appeal and get through.
If you have to contact your state rep, do so.
The state doesn't want you on welfare or disability so if it comes down to it, they will fight to get you the surgery.

I'm so sorry you are still battling but you are chipping away with each meeting and phone call.

Stay tough!

Yeah, I have all of my notes/surgical reports/Mri's etc... I'm pretty meticulious about it. I have them in a binder and It's pretty full. That's sad isn't it?

Thanks, everyone, for your support. It means a lot.

When my surgeon came into the exam room today, he was carrying a stack of papers about 1 1/2 inches thick...pointed to it and said it was all from trying to get insurance approval.

His one comment was that he is getting really sick and tired of everyone practicing medicine without a licence and telling him what he can and cannot do. I'm afraid this is just the tip of the iceberg for all of us who are spoiled here in the US.

On another note, I suggested to him that my nerve pain symptoms were changing and were somewhat different from the last several years, and perhaps I should get a new MRI. He wrote the orders, and I will be going in Monday. Hopefully it will show some new things....

Oh, and one more thing regarding records...when I was talking to a nice, helpful person at my insurance company one day last week, I had sent one somewhat cryptic email to no one in particular, which I never got a reply to...but I found out that they had a copy of it in my file! The helpful guy told me we could do everything online and did I want to switch so that all my correspondence came online? I told him that I needed everything in writing because I wasn't sure that email correspondence would hold up in a court when I sued to get my surgery approved.

Again, my point is that it's great to do things online, but sometimes it is important to have paper copies of correspondence, etc. You never know when you may need them!!

G.

I'm sorry to hear that you are still having a problem with your back. I don't know if you remember me.... I had the microdiscectomy 2 times on L5-S1 last year that left me with permanent nerve damage. I am doing the trial Implanted nerve stimulator now ( it will be taken out tomorrow) It has been wonderful!!!! I have Humana Insurance and we had to fight with them to approve the trial unit and now will have another round to get the final one placed. Has the stimulator been an option for you at all?

Sandy

Gwennie, I so sorry to hear what you are going through with the insurance. I WISH our legislators would get a clue. An actuary as defined in the dictionary: ac·tu·ary
–noun,plural-ar·ies.
1.Insurance. a person who computes premium rates, dividends, risks, etc., according to probabilities based on statistical records.
2.(formerly) a registrar or clerk.

And to top it off becoming an actuary is the #11 top college degree. So insurance companies pay more in those peoples salaries than it does for most patients care.

How dare a clerk decide what care you require!! I am always astounded by what some insurance companies do to their insured. I wish you all the luck in the world dealing with supposed requirements. Funny they cannot describe their requirements.

You gave great advice on medical records. Keep them people. I too have a binder.

Keep after them!!!
Traci

always as being the 'black knight' as being described here.
Sure, there are problems with our Health system, here in the USA as well as other countries Health systems.

Insurance. Just take a step back about 15 or 20 years. Insurance premiums were a lot less and the idea of pre-certification and reviews really did not exist.

Some of the reasons that began to change was because of the increasing number of law suits initiated by patients against their doctors and/or hospitals.

Now here we are today and the rules are stricker and approvals become tougher.

The way to ensure you get the appropriate treatment

- Keep accurate records
- Maintain CD's for all of your MRI's and X-Rays
- Request medical records for all of your major visits.
- When using online methods, make sure you include delivery and read receipts for all correspondence.

Insurance companies are not the enemy. They are just operating under guidelines imposed by the laws of the Health systems.

I have heard repeatedly for those in the medical field that so many 'denied' requests would never happen if the patient did all of their homework from the beginning.

I am sure each situation is different and I can not say if one case vs another is right or wrong. But today, the emphasis on making sure you get approvals rest on us, the patient.

Sorry to hear that you are still having troubles, I was kinda hoping it was some "clerical" error.
Know that you are in my thoughts every day. You are always there for the rest of us, now it's our turn.
Lean on your Spiney friends whenever you need to, were right here for you.
Kylie

What I think I am seeing is a general crack down on unnecessary back surgeries. The increase in spinal surgeries has been quite astounding in the US in the last ten years, statistically speaking. I think with all the focus on healthcare lately, insurance companies are re-examining their criteria for various surgeries. I have noticed that more and more companies are using this Milliman care guide which has very specific criteria for surgery.

And, anecdotally, surgeons are reporting more initial denials.

I'm not quite sure how I can meet these guidelines as one criteria is neurological claudication...but they won't accept an EMG test result as proof! I guess that's what the appeal is for -- when you fall outside the specific criteria.

All I know is I am spending a great deal of my life on the phone with various people connected to the insurance process!!

I am facing the same insurance nightmare. I was supposed to have discogram on Friday. The last time I had fusion, they wouldnt accept a non weighted one. So I had to go through appeal on it. Then after I went through the state appeal, that Dr said if I had a weighted discogram, I would definitely need fusion. So I had the weighted one.
Now, we are going for the weighted one, to avoid the appeal from that, in Mpls, as there is no one in Iowa that does them. Now insurance company is giving the run around about it being out of network. Which has a 10,000 ded. But since no one does them in Iowa, Not even U of I, I have to go to Mpls. And they have to pay in network, as there is no one in Iowa. Geezzz , I cnat figure out which way they want it. They set the precedence with the last go around. And I have the documentation to prove it. ARG
It is so frustrating! Good Luck wih yours, hang in there. Im thinking of you. Take care, Robin

Read your comment about the amount of back surgeries....It's so true. Here in Reno one of my Dr.s told me that more back surgeries are performed here than any other procedure, so it's no wonder that the insurance companies are making us crazy.

Hope it all works out for you.

BTW, my Dr. won't accept Medicare anymore and I have to pay him out of pocket and hopefully get reimbursed from my tertiary ins. carrier. I've had this happen before and my poor husband gets stuck with all the paper work. Sometimes it takes months to get it resolved sometimes even longer.

with the insurance company!

I am so sorry you are still dealing with all this and i do pray you will prevail and get your surgery in the end.

I too am fighting with my insurance company over a different test but its got me going around in circles and getting me no where. No point in getting into the details but I can understand your frustration, as insurance companies just don't seem to budge!!

Hang in there, stay strong, and keep fighting!!!!!

Good luck with your MRI,
Sandra

I too was denied a fusion by Aetna. Their reason was that "Spinal Fusion is considered experimental as treatment for DDD" Within 48 hours of denial my surgeon did a peer to peer telephonic meeting with Aetna's surgeon and explained why I need this fusion (treatment for failed ADR, this is our last chance to fix this level) and was able to get it approved.
Last year I had Cigna and had no problem at all getting an ADR approved the first time. I don't understand that at all as ADR is still relatively new in the US.
I really despise the fact that it is up to these insurance companies to decide whether a specific treatment will work for us or not.
Don't give up Gwennie, keep fighting and make them cover this for you. They have to understand that each case is different and they have to treat them as such.
I am wishing you the very best in your fight with the insurance company, don't give up...fight the good fight!!

I am so sorry you are still going through all this. I truly hoped you'd have an outcome like Pammie did and by this time you'd be well on your way to surgery.

I've had some neck problems and may need C4 added to my fusion. I told my doctor that if we find I need it let's go for it ASAP based on the direction of surgery approvals turning into denials!

Let me know if I can help in any way as this goes along.

Karin

I'm sorry you have to deal with this nightmare. It causes a lot of concern and I could foresee the insurance companies denying surgeries left and right. But I know that you are the one to beat this and win your appeals. You can do this. Hang in there....Hugs, Meydey

I've decided to just wish you luck and send you prayers.To voice my oppinion of Insurance companies realy wouldn't be in the best interest of this site! Although ,I do have plenty!
good luck, Jim

Aetna, Cigna, Humana, and some other companies are all using the same rule book as of Jan 1st and the criteria for fusion are very specific. You would not get ADR approved now.

Reasons for fusion are:

Spinal fraction with spinal instability and/or neural compression.

Spinal repair for dislocation, abscess or tumor.

Severe degenerative scoliosis....progression of deformity to greater than 50 degrees with loss of function

Spinal tuberculosis

Spondylolisthesis with ALL (capitalized) of the following:

High-grade (50% or more anterior slippage)demonstrated on plain x-rays

Neurogenic claudication symptoms from lateral recess or foraminal stenosis

Significant functional impairment ****

Did you see that you must meet all three of these criteria. Just what is "significant functional impairment" and WHO decides??? This strikes me as their ace in the hole to be able to deny authorization at will.

I was told I did not meet the standards for neurogenic claudication or radicular pain. I told the woman I had two EMG (nerve conduction studies) reports, one from a neurologist, the other from a physiatrist, both stating I had chronic radiculapathy at S1...that the surgeons used to tell me I had radiculopathy....She told me that they didn't accept EMG reports as they were subject to interpretation.

I feel like I'm having to play their game on shifting sand. They keep changing the rules on me, or so it seems.

My surgeon had a physician to physician contact call too...finally. They missed the first three appointment times but finally their doctor called on the 4th previously set time. They talked a half hour and my doctor said their doctor understood what he wanted to try to do and why...and he said the surgery would be approved. That was a Thursday night....we heard nothing....Finally, Monday afternoon at 2:30 there was a message left on voicemail stating my surgery was denied. (Surgery was scheduled for 9 the next morning.)

My surgeon has been trying to find out why ever since. As close as either of us can come is "I didn't meet the criteria" and it was not "medically necessary." None of this was spelled out in our policy. My policy says it covers surgery....

I know they just want me to give up...Well, that isn't happening.

---------------------

Thanks to everyone for you support and kind words. I really appreciate it.

Well , now that we have "health care", I wish everyone good luck with trying to get your surgeries approved by the insurance companies. They're going to raise the rates so high that it will make it almost impossible for any of us to get the care that we need. We will all be expendable as we have outlived our usefulness. Some darn bureaucrat with no medical experience is going to be responsible for determining what we need.

GOOD LUCK TO ALL OF US!!!

I know I am lucky to have excellent health insurance. And when I have had to deal with W/C and no-fault car insurance I have been very lucky as well. I'm also not afraid to get on the phone and ask for help and info. I don't take no for an answer. Often getting the right answer is a matter of know what the right question is. Also I have found it is better to use honey with the person on the phone. Often they have limited authority but making them mad will not help. If they can't help you ask nicely for a supervisor.

All that said. Gwen are you able to use the threat that prolonging the wait for surgery will cause additional damage? Often that is a huge weapon to use. Also are they paying you anything for being out of work? I know when my husband hurt his knee I had him approved and in surgery 3 days later because every day they waited cost more in W/C.

Good Luck and try to remember the person on the phone is just doing their job.

Prior to 22 February, I would have said that I have always had excellent health insurance...top of the line coverage, best companies, etc. This denial totally caught me by surprise. They have paid everything else with not a single question, up until now.

I understand the point you are making...but my surgeon has not had any more luck getting phone calls returned or finding out a reason why I did not meet their criteria. I am always polite when speaking to anyone on the phone. I'm just expressing my frustration here on the forum.

Since you can't really predict how quickly nerve damage progresses, I don't think there is a way to predict what will happen in the near future. Actuaries don't care about the pain one is in, and how much it limits "life" as we previously knew it. I would have to develop cauda equina syndrome to meet their qualifications...and I'd just as soon skip that. Otherwise I need to develop a greater than 50% spondylolisthesis along with several more things to qualify for fusion.

Employment does not enter into my equation.

Had I known what I know today, I should have moved faster and scheduled my surgery in December 2009!!

I can't imagine having to have had to deal with all that prior to surgery. My heart goes out to you! I work for a radiation oncology office and I do the pre auth calls for the radiation treatment for cancer. We never even used to have to worry about getting auth for radiation, for God's sake it's cancer!! And now alot of companies require authorization. The Whole insurance world rules medicine. It's not right. Good luck on your approval. Lynette

It wouldn't have been so bad if it hadn't gone down to the wire. Finding out sixteen hours before I was due to the hospital was a bit much. Thank god I hadn't asked my daughter to take time off from work to fly home and stay with me for a week or two. Then I really would have been unhappy.

I'm feeling fairly positive that I will get approval on appeal, assuming the doctors who are on the appeals panel, or whatever it is, actually read what we are sending them. I have been assured they would, but who knows?

Just got back from having a new MRI. I swear that tube has gotten more narrow!

It really sucks with the power insurance companies have,it'ts not about the patient but money they can save. My insurance going up 30% I worked in the medical field for over 30 , health care has gotten worst not better.
When ever your fighting a Doctor or Insurance company
you make sure you tell them to put in your file it's affecting the quality of your life,that's a permament notation.
Hang in there
john

Gwennie...back to your situation, yes, the MRI tube does seem to get smaller each time and they seem to keep you in longer each time.

I never had an issue but find that each time I go back and they ask me...I think, hmm, what if this time I get an anxiety attack.

They should just put a blindfold on you so you can see how small the tube is. They should also give you a glass of wine too before so you can take a nap.

I hope this is just helping you get 1-step closer to an approval.

I've been getting great tips from lots of people. I do appreciate it. I just got a chronology of events from my surgeon's surgery scheduler so now I better understand the events leading up to where we are today.

On the one hand, I do not blame insurance companies as there are many procedures and surgeries scheduled that are probably not in the patient's best interest. But obviously in something as dynamic as practicing medicine, we aren't all going to fall into neat little categories, meeting each and every requirement a group of actuaries has deemed necessary. When my surgeon, with all his years of training and experience feels like everyone is practicing medicine without a licence and preventing him from practicing medicine, things seem rather out of whack.

Hi Gwennie! I finally have felt well enough to dig up my letters from BC/BS out of Minn. (although I live in Tx~they varying policys in different states)

Lumbar fusions w/out instability deemed medically necessary for chronic back pain (present 6-12 months) when ALL the following criteria are met

1.anti-inflammatory meds and analgesics

2.physical therapy which includes a. passive treatment modalities (thermal treatments, elect. stim.,mechanical traction)and b.active, organized and progressive therapy program that includes strengthening, flexibility, balance, coordination, and postural education and C. instruction and trainig in the use of dynamic activites to improve functiona and performance and

3. theraputic injections and

4. the patient must be evaluated preoperatively by a psychiatrist or licensed psychologist (Ph.D.) to ensure the patient's ability to understand, tolerate,and comply witha all phases of care.

5. Radiographic studies (e.g. MRI,CT, CTmyelography, discography)

The psych eval was something that is not needed in Tx, so it was a surprice and resulted in my surgery being postponed the night before. After completing that, and while waiting for BC/BS to receive the paperwork and review, I started going down hill fast, falling, unable to work, inability to complete ADL's. So while waiting we were able to identify who specifically was reviewing my case. I called her multi times and politely explained what the delay would cause me in terms of my own health and safety (falls) and not being able to work. I emphasized the freqency of my falls and what could happen if I hit my head, my own good health, and what the ability to return to work would result in (ie I played the sympathy card as I work with babies who are micro premies and others with special needs. After all, who can deny the smallest and the weakest!) It worked! Because I established a relationship with her, and everytime she saw my name on a piece of paper, she had an mental picture/association to go with my name!

Hope this info is helpful! Gwennie~I will continue to pray for you! I know you will get your approval. All things happen for a reason! Hang in there!! hugs! Shari

Thank you for taking the time to dig out your papers. I do appreciate it.

I think you will find the standards have tightened up since the first of the year. In the Milliman standards that I have referred to previously that many companies are now using, there is no acceptable combination of criteria pf any sort for chronic pain. Pain of any sort is not considered for the purpose of fusion or decompression.

How did you find out who was reviewing your case? I was told a "panel of doctors" would evaluate my appeal.

Since when do a panel of retired Doctors, on the insurance companies payroll, know more than a Board certified orthopedic surgeon? Most of those Dr's. on the panel were just general practice M.D.s
Both my Surgeon and my P.M. Dr. love to do battle with them!
Good luck, Jim

This is the criteria BC/BS of Minn. used for 2010 approval. My approval was given 2-9-10 using the above criteria.

BC/BS sent us a letter stating that we needed the psych eval with a reviewers first name. It took several days to find her, but we did. She then passed us on to the person that was currently reviewing it.

After my 2nd missed surgery date, my surgeon got involved also, speaking directly to the reviewer.

Just keep chipping away! You'll get there!

Hi all ~

Just an update -- I finally got all my records from various "second opinion" surgeries, dating back to 2007, got my current surgeon back from a ski vacation and got him motivated to write his letter, and got it all assembled this morning and mailed off to the insurance company.

As I understand it, they have 30 days in which to reply to the appeal after receiving it.

So, wish me luck! What a weird situation to be in. Most people dread the thought of surgery, and here I am, praying that I will be allowed to proceed.

Cheers ~
Gwennie

I know how hard this is and how it feels to feel as if you "have all your eggs in one basket". Good luck!

Do you know whether it is 30 business days or 30 calender days? Hopefully, it's just 30 days! And here's to them passing quickly with as little pain as possible!

Wishing you luck! Shari

The reason that you are praying that this will go ahead is because you NEED surgery.
Let's hope they realise that and pass it.
In the meantime, stay positive.

I am in hopes that once they recieve you appeal, they will swiftly process it and approve you for your much needed surgery. I know how you feel, I have been there and the wait is so umberable. Every day waiting to see what will happen. I am sending lots of good wishes both for the approval and also to give you the paitience it takes to wait. I understand the wierd sense of wanting surgery. It is sad that we must be in so much pain, to wish this on ourselves. But with the surgery, hopefully getting your life back where you want it.
You are so supportive of everyone, that I know that all of us, combined, praying for a good answer has to be effective. Take Care, Robin

I hope your appeal will be processed before the 30 days and that surgery will be approved. The mind still boggles at how they can say that you don't need it. The waiting will be hard but we're here for you.

Trish

Hi Gwennie!
I'm so glad you got all the information together and in the mail for an appeal. I'm praying all goes well and you get the approval.

I wonder if it would help if your surgeon re- dictated, with all of the new information. And sent the insurance a new dictation (request)
Would it confuse things. Or being a new request, armed with more information. Would it force the insurance to regard it as a totally new request. And approve or deny on a new dictation.
They are, in my opinion, trying to wear you and your team down. By overwhelming everyone with paperwork and such.
Why not try to wear them down with all new stuff to fight!
FIRE WITH BOTH BARRLES!
Good luck, Jim

I wish the President of the Insurance Company had a family member in pain who had to meet that same criteria that you did -- It infuriates me to hear stories like this and I've heard them often.

You have to become a nagging pest and ply them with paperwork and phone calls. Now I know why people get so fed up that they chain themselves to trees (or walkers) in protest.

I know you'll win out in the end -- just hope it's sooner than later for you.

Take care,

Judy

It is my 3,000th post and I am using it to let you all know that I got a letter from my insurance company today advising me that the hearing for the review of my appeal is scheduled for Wed. May 5th...between noon and two pm.

I "may choose to attend either in person or by telephone." I have to let them know by Friday if I, or a representative, wishes to be there.

I can't decide what I want to do. I wasn't expecting to be allowed to appear at the meeting...and it is scheduled in a city about two hours from where I live, so I could go if it is the right thing to do.

Any thoughts?????

Go, Make them look you in the eyes! I really hope you win!
Good luck, Jim

I would go too! It is so easy to make decisions based on numbers and data. Make them look at you, hear your voice and realize how their decision will affect YOUR life.

I wish you the very best and will keep you in my thoughts and prayers. Don't go alone. Have your hubby, family member, or friend go with you. You will want their support. You may feel incredibly drained when the meeting is over.

We'll be here, cheering loudly for you! xxxx Shari

Hi Gwennie,

I'm glad you got the date!
Now as for going, it's a catch-22. Can you ask a lawyer if it will help or hurt? I would, at a minimum, listen in.

I'll be back after I give it some thought.

Make them look you in the eye and say you are fine! Being there shows that this is important to you. And remember we will all be with you in spirit. Might need a larger room......