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Anybody had their insurance deny surgery?

AnonymousUserAAnonymousUser Posts: 49,671
edited 06/11/2012 - 8:26 AM in Back Surgery and Neck Surgery
:jawdrop: :jawdrop: ~X( ~X( OMG! My MRI and back are a mess, the friggin' insurance is denying my claim!!!! The denial letter said, "Spinal fusion is not considered medically necessary as a treatment of low back pain due to degenerative disc disease or degenerative lumbar spondylosis in the absence of spinal stenosis." On both my MRI's and in two of my surgeons notes - "mild spinal stenosis is noted." I am so frustrated I could cry! It is now going to appeals and then I will take it to the insurance commission. I am wondering if they are rejecting it based on the fact that he wants to use the artificial discs. I even asked the precert lady if I went with a "standard" fusion, if they would approve it. She told me to keep going with the doctor I have, let it go to appeals and see what happens. I am so scared that I am going to have to live with this pain the rest of my life. :''( I just needed to know if anyone has been through this and if you eventually got denied or accepted?

I also feel like I need a few hugs, I am so upset! >:D<


  • i had my insurance company deny my surgery and I went through the appeals department. Had second appeal and it went to insurance commissioner. It was sent out for independant revieew. The reviewer had to deny my claim casue the discogram results were not sent. Make sure you send all the tests that you have gone through. The discogram had to be repeated becasue the pressures were not recorded. So the reviewer said after I had it redone and the tears in discs showed it was then medically nessasary., Redid the test and they denied it again. I was furious and called the CEO of the Company. She referred me to Med Director of the region. The med Director called me, reviewed it over the weekend, and called me on Monday and approved it. It was very frustrating, but dont give up.
  • Oh no, that's awful! As if the pain and thought of surgery wasn't enough!! @) :''(

    I didn't have any insurance problems so I can't help you there, but I'll be the first to give you a great big hug.

    >:D< >:D< >:D< >:D<

    Take care and I'm anxious to hear about the appeal and if other people have experienced this. It's simply outragious! :jawdrop:


  • :''( Thank you! I posted my MRI picture in my profile. Hard to see my spinal cord which is almost pinched off. I am so mad! Have paid premiums all my life and then when it is time for them to pay, they won't. ~X( :S Your story gives me hope to keep pushing. I don't know how they can deny it when they say that they will do the surgery with spinal stenosis and I have that and they still say no. She said, "well maybe it is not enough." How absurd is that? Stenosis is stenosis, there is nothing there that says until it gets xxx bad!
  • My Dr wrote a 6 page letter as well. He told them eveything I had done and how bad my tears were, and everything. Get together all you physical therapy progresss notes, all pain medicine procedure notes, every dr that you have been too. That will help your review with the outside expert from the state. Anything you have done conservitivly, will help your case. I had three torn discs and had been through it all. Physical, aqua therapy, all the procedures at pain clinic. The more info you have for reviewer, the more strong your case. And your Dr explaining how bad your condition is. Dont ever give up. If I can help, let me know. I had gone through the worst to get mine approved but it was the internal medicall reviewer at company that had a vendetta with me and my Dr after my Dr told him that the reason he worked for an insurance company is because he wasnt a good Dr. Ooops, maybe that was bad, but he was being a jerk to my Dr., :))(
  • Now I really think my insurance is nuts...
  • I feel so helpless, I don't know what to do. I know what it is like, the first procedure I was going to have was considered experimental so they denied me. I considered paying for it out of pocket(my husbands suggestion) but I decided to get another 2 opinions. I am glad I did. I got the right surgeon and feel great, so will you. Your insurance company is being a *****. I never even got a bill for the surgery! Figure that out. I guess I had paid my yearly maximum out of pocket(250.00). I had an ADR and they never questioned it so go figure. Don't give up you will get it approved. Lots of hugs coming your way, stay warm it's getting cold.
  • =(( I am just so frustrated. X( The second precert doctor denied it as well so I am not sure what they want? This is the fourth doctor that told me I need it. I honestly think it may have something to do with the Titan discs. If they completely deny it after I go as far as I can, I will resubmit it with the doctor from Froedtert and get the standard fusion done. Anything has got to be better than what I have now. I am finding out what a bunch of creeps these insurance companies are L) , I have seen it in healthcare, but this is the first time I have experienced it.
  • I have always had lot problems for example my Dr ordered a CT scan and an MRI. My insurance required that a third party evaluate why the need for both. This took 10 days for the approval....meanwhile I can't stand up and have emergency room pain.

    Another time my PCP orders an xray which sould be covered 100%. The Dr coded it to an office visit....so I have to pay a copayment.

    My insurance requires me to go to a certain location for blood tests which is a 40 mile round trip. And I have a hospital 3 miles from the house.

  • Dude, your back - wow! #o :jawdrop: Holey moley lots of hardware there! Thanks for the info. I am just going to have to keep plugging along and filing grievances, etc... I thought it was more common to get denied, but from the lack of responses here, I am thinking my insurance company is full of brainless idiots more than I thought! :W
  • You just have to keep appealing. They hope you will give up and go away. Make enough noise and show persistence and it should work. Actually, you should go buy Laurie Todd's book the insurance warrior. She shows you how to make them pay. Its only like $10 I think. Google it.

    Good luck!
  • After being on this site for so long. I have found ALOT of insurance companys will not pay for the artifical disk.
    Stenosis is painful I only know that by hearing the other pts in my ortho's office when I go there. He usually tells them after PT if nothing helps surgery is the only option.

    Mabye its the way the letter was written to the insurance company?? Not sure as I have never had this issue, but I know if its worded the wrong way just a little BANG.

    Just keep going, keep fighting the issue!!!
    This is what my insurance company requires from the Drs office before any surgery:
    Type of surgery.
    Reason for surgery.
    What will happen to the pt if the surgery is not performed.

    Also really try having the drs office submit it as having a fusion with your own bone instead of the ADR.
    May make a huge difference in their response.

    I wish you the best of luck!!!!!
    Terri O:) O:) O:)
  • That could be the reason, although they don't want to admit it. I am going to try to go as far as I can to get this paid for, because I have a lot of confidence in my surgeon and I want him to do it. But if I can't, then I think I will try to get a more "regular" fusion done - maybe they will be more inclined to pay for that. Anything has got to be better than this pain I am living with day in and out. I just hope they did not set a precident by refusing the first one, thereby having to refuse the second as well... oye! 8} :<
  • My insurance company denied artificial disc replacement. I too apealed all the way to New York state insurance dept then finally went with fusion which they did pay for. I wish you the best of luck. It is difficult dealing with insurance approval on top of all the pain you are experiencing.
  • Did they do like a compromise or what? :/ Did they flat out refuse the ADR and then offer to do the fusion instead? How are you doing now? Thank you for your reply!
  • Thanks for the PM heads up to let me know you had more questions. I appreciate that since I check my pm's more than topics i've posted.

    My doc pretty much new the adr would be refused since my insurance has yet to approve it due to experimental/investigational however, he knew they would approve the fusion due to past experience with patients that have same insurance.

    I don't know if it would've made much of a difference which surgery I had in the short term. I think I would still be feeling like this. What I mean by "like this" is that I am still having a lot of nerve pain. I don't know if it's just because my nerves are healing from everything and I just need to give it time or if it's permanent nerve damage. I am going to a neurologist and have nerve tests done at the end of this month to find out. My ortho surgeon told me in the long run, a fusion usually puts strain on your health discs above or below fusion, therefore 5-15 yrs down the road, I may need another fusion or surgery at L4-L5. It all depends on how my discs responds to this fusion.

    I wish the best of luck and you really should talk to you surgeon about alternatives in case your insurance does not approve this. In my case the insurance company did not offer and alternative. They just refused the surgery requested and then the surgeon put in for approval for the fusion and that was approved immediately. I also have over 6yrs of documentation that I've tried all kinds of conservative methods that did not work for me. Everyone is different though and responds differently to treatment so I hope that I did not discourage you in anyway.

    Good luck with your insurance and please keep us posted on your progress.
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