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AnonymousUserAAnonymousUser Posts: 49,900
edited 06/11/2012 - 8:25 AM in Back Surgery and Neck Surgery

Hello everyone...
I am very frustrated and don't know where to turn. If anyone can help pleae let me know!
Here's the story...I started having pain in May 2008. I started going to a chiropractor which after about 4 weeks he sent me on to a NS. The NS started me on physcial therapy, then sent me on to pain management where I received 3 epidural injections over the next 3 months. After exhausting all of these with no help to my back the NS finally decided that I need to have an L4/5 TLIF. They ran it through insurance before scheduling where insurance denied the claim saying I didn't meet their "criteria" for surgery. The NS appealed this claim and then spoke to insurance doctors and still denied this claim. Yesterday 11/21/08 my NS sent me for another MRI to see if this would help in the appeal.
My NS is very upset that they would question his judgement after being a surgeon for 35 years. Obviously this isn't the first time this has happened but it never seems to make it any easier for him.
I'm in waiting mode to see what the insurance co. says about this 3rd appeal. Has anyone had experience with this if so...who did you contact in order to get something done? I am in SOOO much pain and am needing this ASAP.
Oh, and I forgot to mention...I really think the insurance co. is holding off til the first of the year because we are almost at our "out of pocket" expense cap for the year which means we would pay very minimal for this surgery. So I think the insurance co. is trying to make us hold off til the first of the year ~X(

Help help...anyone?


  • I do see how frustrating it could be to be denied 2 times already. I do feel also they have refused it to not have to pay the cost for it. ( I have worked with insurance comp before) they will try anything and everything not to pay for it. But there are always a way around it. Good luck and I hope you get your surgery you need... Kelli
  • that you are going through this. I would call and ask them what the bleep they want. I can be nasty at times when dealing with pain and getting run around. Do they want a second opinion? Or for you to try another nonsurgical treatment option?

    >:D< >:D< >:D< >:D< >:D<
  • Did you speak to a Supervisor? Perhaps the surgery is under another name? Sorry for all the trouble you're going through and hope you get it resolved. Can your PM Dr. and family Dr. sign the need surgery form? They can't turn down so many Drs? Take care. Charry
    DDD of lumbar spine with sciatica to left hip,leg and foot. L4-L5 posterior disc bulge with prominent facets, L5-S1 prominent facets with a posterior osteocartilaginous bar. Mild bilateral foraminal narrowing c-spine c4-c7 RN
  • I am willing to try anything...even if that means getting rude! }:) ~X(
  • No, Charry I haven't actually contacted the insurance co. myself because the doctor's office said they would take care of it all. But, as of yesterday...the NS said try everything...call the insurance co., talk to my local insurace rep., speak to state represenative that deals with insurance board, he also called the local paper and wants me to do a report outting the Anthem Blue Cross Blue Shield for denying this claim which by MRI seems so resonable.
  • to the insurance company stating that this surgery has been requested this year and so falls under the catagory of this years 'budget'.Also state that you suspect they are putting it off for no other then financial reasons.
    Get a Justice of the Peace to witness and sign the letter before you send it to them registered mail.
    This way when they do finally approve it you have a leg or two to stand on legally.

    Dont give up and it probably is a good idea to get a second opinion as well to back you up.

    Blessings Sara O:)
  • If nothing else works call a lawyer.

  • All I can say is that if they do deny it this year and approve it next year, you have paper work stating that they requested it this years and take them to court and make them cover under the previous years filing information.. That is all I can tell you to do. I am sorry that you are going through this, I know they can be a pain in the butts....
  • Lawyer, Lawyer, Lawyer! Once they see that, you will be surprised how fast things turn around.
  • I was five years fighting the MCO that my employer uses to get my operation. I guess one question is, was this a workers comp injury? or are you going through your primary insurance company? If you are a workers comp injury, you can call your Ombudsman's office. The problem with all insurance companies is they lack any compassion for what you are going through. They are profit oriented. Period.
    If your injury is a Workers comp injury, I would suggest getting a lawyer that specializes in Workers Comp injuries. If yours is a fight with your Primary insurance, request a meeting with the claims rep and find what conditions are needed to be listed in your claim to satisfy their reviewing Doctor. You can do this, do not give up. I felt all through my fight for treatment that all the insurance company wanted is for me to walk away and give up. Do not walk away. best of luck Steve
  • charry said:
    They can't turn down so many Drs? Take care. Charry
    5 years ago I had 2 OS, 1 NS, 1 chiropractor, my PCP, my PM doc and a reconstructive plastic surgeon all who documented in writing that a breast reduction would decrease my mid back and shoulder pain significantly. I was denied on 3 levels of appeals. Pretty much told, that their doctor, who never even saw me, says they are all wrong. Insurance companies can get away with so much. The damage to those discs could have been slowed down with that surgery. Now I can look forward to those discs continuing to deteriorate. I allready had 1 shoulder surgery and looking forward to more. OK enough venting, sorry.

  • I love your last line of your signature. I feel ya there. I get 90 percocets every 8 to 9 days. I also take Valium, but thankfully right now that's it. I used to be on Dilaudid as well, Flexeril, and a few others.
  • I missed it, (I may have) yo never say why you failed to meet the criteria?
    Can you challenge that?

    Perhaps you can suggest a case that discusses even more expense to the insurance company long term if they deny you prompt treatment?

    I am in UK. Here patients are usually left for a year trying other methods of pain control before surgery is done, unless it would be stupid to sit and wait for clinical reasons.
    I am not sure where you would sit if you were to live here...perhaps that may help you see rationale of the insurance company??
    I don't know - is it the same? will you have to suffer a year to prve worthy of surgery?
    Good Luck.
  • Good luck to you on your Surgery, my injury is also work--related,i got hurt jan 2004 went to Chrio for over 2 years had every injection.. was placed in a lite duty position, re-injured my self in july 06, my foot got caught in the reil road track, boom my left side hit a beam i went dowm!! had to have surgery nov 21 06,(could hardly walk).went back to work 3 months later sooo stupid, started seeing a pain Specialist in Dec 07,being in lite duty they can place you where ever and whenever,,, In March 08. doctor took me off work.. di every test whatsoever, now all my test r positive i am waiting for approval for Reconstructive Surgery,, i have to do this all over again and since the doc left the bone out do not understand a now the rods r un-even, also they have to go a level higher the pain is bad,, going to work comp doc so he can read my MRI again. i do everyhthing they ask and they keep wanting mor i just want to do the surgery . and go on with my life,,I hope all goes well with you and so sure it will i hope you got a terrific surgeon, this time i got 3 opin smarter this time and in no hurry to get back to work!!, take your time your job will be there dont be boo boo the fool like me iam so suffering now!! good luck to you
  • I was scheduled for surgery on 11/5 and the day before I received a call from the NS stating it was denied for the same reason. I am on my 3rd appeal and will no something on 12/5. I asked my insurance company if I can't have the surgery than give me another option. I have tried all non surgical forms. I think they want you to be half dead before they approve anything
  • I'm sorry to hear you were denied that surgery. I often wonder if I need one also at 44DDD. I think the weight is alot on my back. Take care and wish you the best. Take care. Charry
    DDD of lumbar spine with sciatica to left hip,leg and foot. L4-L5 posterior disc bulge with prominent facets, L5-S1 prominent facets with a posterior osteocartilaginous bar. Mild bilateral foraminal narrowing c-spine c4-c7 RN
  • Thank you to all who responded! I unfortunately haven't heard anything back since the last MRI and since they have resubmitted the claim. Please let me know how your third appeal goes. What insurance co. do you have? Just curious if it is the same one as mine. What surgery were you to have? Hope everything works out ok for you....I wish you well. You all have been so great...I love getting ideas on what to do so I can at least feel as though I'm in control of something...because I feel so powerless right now. I hate that the insurance companies have so much power over our bodies. This is totally out of control! ~X(
  • I've been getting the run around from me WC claim. worse my company is self insured. however my lawyer has sped things up to say the least. they're still fighting on my wages but we'll see. if anyone needs a good WC lawyer in Vegas or Reno PM or email me. MINE ROCKS!!!! hope things work themselves out. hang in there. we're here to prop you up :-) >:D<
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