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My insurance company denied

DIFerrisDDIFerris Posts: 86
edited 06/11/2012 - 8:32 AM in Back Surgery and Neck Surgery
authorization for my fusion surgery. I just found out late this afternoon. I had no idea that it hadn't be authorized yet.

I am so upset, I don't know what to do. I called them and the doctor said that they did not receive enough documentation of conventional treatments being used to date. Mainly he said that I did not go to physical therapy after my last surgery. I told him the pain was worse after the surgery, but I was told that they have their guidelines that they go by for authorizing.

I have gone through 5 rounds of physical therapy, countless prescriptions for pain medication and 2 surgeries already! I have had every part of my body MRI'd, CT'd, ultrasound'd and whatever other test that could be done.

I have to wait until tomorrow to talk to my doctor and see what happens next. I can appeal the decision. I need to talk to him first. I am in so much pain. I can't drive because I can't twist even a little to look over my shoulder, and pressing on the accelerator causes my right leg to spasm and cramp up.

Either way, the surgery on Thursday is not going to happen. I was crying after I got off the phone. I can't go to work, and I don't really know what is going to happen now.

I'm sorry to go on like that... I guess I just needed to get it out.



  • I am so sorry. I know this is devastating and I realize how much you need this surgery. Hopefully it can be appealed and your doctor can show that you have already tried PT in other occasions. Don't give up; the fight's not over yet. You know you need this, and so does your doctor and I'm sure he will assist you in getting this done. Hang in there and take care >:D<
  • I don't even know where to start.. maybe someone will direct me to the correct forum. I am having what is most likely symptoms from degenerative changes, foraminal stenosis, disc/osteophyte complex and compression of the C6 exiting right nerve root. Bad headaches, head positional tingle and numbness down the back right shoulder blade, down the bicep, forearm and into the thumb and first finger. A neurosurgeon has evaluated my mri, the soonest they will see me is the 23rd of next month. Is that common for them to make you wait for almost 4 weeks? I am seeing my doctor tomorrow to get a second opinion neurosurgeon lined up, I don't even know what the first one is going to say yet. I'm 45, very active, now I'm afraid to move for fear I'll make something worse. My sinuses were a problem, I just had a revision surgery in May, when the headaches didn't resolve and the neck issues heated up, I guess sinuses were only part of the problem. I guess if I have just one question for now, if I'm looking at maybe a foraminotomy or something fairly minimal, is there any restriction on physical activity once you have recovered?
  • Deanna - I am so sorry. I know what it is like to be so ready to be rid of the pain, only to be told that you will have to wait. I was supposed to have fusion surgery in August of last year, but ended up having to wait until November when my surgeon decided that she wouldn't operate on me because I had more than two levels to be done. I had to find a doctor two hours away from my home town to do my surgery! I truly hope there is something they can do to get you in that operating room on Thursday. This is so not fair.


    3 level spinal fusion, L3/4, L4/5, L5/S1, November 2008. Stiff, but I can walk.
  • You poor love-I really feel for you as I am in the same position. Insurers have declined my surgery and sent me to other specialists to try to bolster the negative decision. As hard as it is try not to torture yourself with their decision, hopefully they will re-examine the facts and agree with the original request. It is beyond me that people think they know better than specialists, when all you want to do is focus yourself on is moving forward to a better physical place.Thank goodness this site is here and others understand the frustations that we live with.All I have is my best wishes for you and a big gentle hug and sorry you are being treated badly-Hugs n' Loves- Paula
  • Same thing happened to me in July of last yeat. I got notice day before surgery. I ended up going through appeal process only to have it denied by a jerk that my Dr got in a fight on the phone with the first round. Long story short, call your insurance agent, get the number of the person that is in charge of your region . I had the person that was in charge of Iowa and Nebraska. She was the medical director. I called her and got stuff done. I had gone through too much, like you and she made it happen that I got my approval over the weekend. Dont be afraid to go to the top. The sqweaky wheel gets the oil. I will help you in any way I can. I hate what my insurnace co has put me though. PM me if you have any ? Hugs...I know how disappointed you are. I was there..It sucks..
  • Your support means the world to me. I am so depressed today. I am trying not to think about it, but I was finally ready and waiting for this. My surgery was scheduled at the end of May this year, but authorization was not requested at that time. They send that in the week before the surgery. It was sent to the insurance company on June 25th, last Thursday.

    I will call the insurance company and see who I can talk to. I already asked the doctor's assistant when would be the soonest I could get in if it had to be rescheduled and she said probably not for another month. I had already waited over a month for the time I was supposed to have tomorrow.

    I spoke with my NS this morning and he wants to see me next Tuesday. He said he will do a CT scan, flexion-extension xrays and possibly a discogram. He sort of got into it with the Doctor at the insurance company as well. He asked him what he (the insurance Doc) suggested to make me better since the surgery was denied. Of course the Doc at the insurance company did not have an answer for that.

    I called the insurance company and spoke with the Doc that denied me and he did tell me that he is not the final say and I could appeal it. I am going to discuss this with my NS on Tuesday and see if he wants the test results first so that we have more to send them.

    This is just horrible. Ugh!! ~X(

    Thank you again for all the comforting words and the advice.

  • I have to fight the battle with the insurance. It will all work out eventually just don't give up. You are in my prayers.
  • They will help you so they can ensure they get paid. It is in their best interest!
  • They will not let me speak to anyone after a denial of authorization. They told me I have to go through the appeal process.

    This is the first time they have given me any trouble with anything.

    I hope the further testing will be enough for them. If not, I don't know what I will do. Driving is too painful, so I can't go to work right now.

    I guess I will just have to wait and see.
  • You have BC/BS? They denied me too, twice. I sent it to appeals with loads of documentation and backup from my doctor and threatened to take them all the way to the insurance commission for my state. They finally approved it. Don't give up, FIGHT! I sometimes think they reject these surgeries to see how many people will just give up. Good luck!
  • Yes, I sure do. Thank you for the insight into your situation.

    I see my doctor on Tuesday, and I am going to talk to him about the appeal before I file for it. Maybe he can get more together and possibly the new test results. It seems to be the missing documentation that they are looking for.

  • They are famous for doing this type of thing. I saw a story about lady with cancer on CNN or MSNBC and BCBS DENIED her surgery! In essence they were handing her a death sentence. The poor lady had to go all the way and testify in Congress. Other insurance company CEO's were present too. They were asked to make a promise to stop this practice but nobody would commit of course. But the good news was that the lady got the denial reversed and got her surgery at last. This comes to show how pitiful BC/BS is, and that is why I never pick them for ANY type of coverage.
  • Deanna,

    I'm sure the denial is dis-heartening, but may I make a suggestion to take a step backwards and re-exam your position before you have a fusion surgery that cannot be undone. You indicate that you have hip pain and pain down the right leg. This could also be as a result of Sacroiliac (SI) joint dysfunction which has symptoms that can mimic a disc herniation. A really good Sports Physical Therapist should be able an examination to determine if you have SI Joint problems. I personally have SI problems and can tell you that if that is your problem and you have the fusion surgery, the problem will only get worse over time. Maybe a second opinion wouldn't be a bad idea to verify that you are following the proper course of action.

    Just some food for thought.

  • Deanna,

    First let me say - UNBELIEVABLE!!!!! Question - have you had an MRI since having your 2nd Micro-D? If yes does it show re-herniation? That might be all that is needed - you probably have lost too much of your disc that doing anything other than a Fusion makes no sense. That is my case - herniated L5 and lost 70% of the disc - my OS said he could do a micro-d, but thought that I would re-herniate within a year and have to go through a Fusion then - so why not do the Fusion now to avoid two surgeries.

    Keep fighting them - it sounds like your surgeon will help. I know you must be very frustrated, but hang in there - I am confident things will turn in your favor. All the best, Mike
  • So, they denied the surgery, saying that not enough documentation was supplied.

    I was to have a discogram last Monday, 7/20/09. This got rescheduled as authorization was still pending. The new date was this next Monday, 7/27/09. Found out this afternoon that the insurance company denied this as well, saying it is not medically necessary.

    Am I supposed to wait until I have permanent nerve damage, and then nothing will help!!

    I am so discouraged... I have no idea what they want... they want documentation but won't pay for the test that will provide the documentation. I suppose I need to do some research and figure out what to do.

    I plan on discussing this with my NS... however, last time I was in the office, both of my NS's told me that fusion was my only option.

    I feel like I am out of options right now.

    Thanks for listening (reading :) ).

  • Hi, I am so sorry to hear you are in so much pain. That the frustratation is hitting you so hard. I have had many experienceces with denials through insurance companies, I figured I would share with you a few tricks.
    1st of all get a Pain Management Dr. They have their ways around & through the insurance companies. If the say you HAVE to go to PT again (we already know you can not), play their game. When you get their do NOT do anything that causes you pain. (since everythin causes you pain, I will let you read into that what I am meaning.
    As far as your Dr goes it is a matter of the Dr, (go in for an emergency visit if you have to) going through the red tape. They know how to. They MUST get the ear of the authoration dept. & specify that EVERYTHING that has been tried has not worked. It is against Drs' orders for you to go to PT anymore because @ this time you are beyond that & in desperat need of surgery asap. They are to mention that it was already planned on being done until the authorization got denied. The Dr. MUST SPECIFY the reasons why the normal proceduredures are not working for you and that this auth. needs to be pushed through NOW!
    In regards to your leg, that is most likely your nerve pinching on your lumbar. The surgery will help. In the mean time there is not much you can do about it. VERY frustrating I know, I have that with a cyst in the spine @ lumbar. As well as other parts of my body but, back to you. Stretch it if you can, laying in bed. You can also make your tummy tight & bend your legs like a table and tighten until you feel it in your tummy & lowerback, push like having a BMovement, keeping your tummy tight the whole time. Hold to the count of 10 (IF you can) rest, repeat. do 5 the 1st day. THis is a stabilizing exercise. ( If you get nothing other than my careing thoughts out of this I hope you will ALWAYS remember the following; your stomache and back mussles work together. If one is weakened the other is too. If you streghthen one it will make the othe other stronger. This will remain the same throughout your your life & mine & everyones.
    If you can walk around your living room , do it. It will keep the blood flowing & the mussles working in a very passive way. If you have more questions, I am usually in with a ton of smart people in the back & neck pain forum aroun 4pm PST. Most everyone else is from the east coast or out of country. We have 3 nurses. (3 Last count, maybe 4?) You are more than welcome to come in. Don't be shy, jump right in & ask your questions. If you dont get answer first time keep on coming, I swear you will. It is a healing room with alot of smart people who have become friends, & feel like family. We are a bit wounded now from 1 jerk, so bear with us. It will be worth it for you. The more minds working on a problem, the more ideas. Best of luck to you. I hope to meet you in c hat. Good luck. Make those doctors earn their money & fight for you. You fight for you. BTW It is okay to cry, laugh, jole, be silly , depressed in chat. Just do not ever lie. Hope to see you soon. Oh yea no F word either lol u can do f*** lol
    Wish you the best, welcome to Spine-Health.com chat I hope. Good luck.
  • OMG I feel so bad for you. You need to start the appeal process to get things done. After denying you you have the right to appeal with in the company. If the deny again you then go to the state level with an appeal through the state insurance commission. They will put it to a independant firm who will look over your case and see if this is a procedure you need. That is how I got my fusion done. It takes some time, and like you they denyed my surgery the day before. But this is the correct way to fight and win. Maybe contact your personal attorney if you need help with it. Or I will guide you through it. It is total crap that they can do this to you.

    But start getting all your medical records and a letter from you surgeon stating why you need the surgery. My ortho wrote a 6 page letter for me. WHatever you do, fight them on this. Its just wrong. Hope I can help. I know how it feels, and it breaks my heart that you have to walk the same path I did just to try to get your life back. Hugs to you, my friend. Love Robin >:D<
  • Thank you so much for the information and suggestions... I really appreciate it! I have never had to go through this with insurance companies, so I was really at a loss. You have given me some great advice! I guess it is not that uncommon after all!

    I will definitely be getting all of my records together from the past 4+ years. I am going to appeal this.

    Thank you for the comforting words, as well. I have not been on much lately.. trying to process this all has really gotten to me. I think once I put the appeal in motion, I will feel better about it, or at least not let it consume me so much!

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