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Spinal fusion surgery denied

AnonymousUserAAnonymousUser Posts: 49,671
edited 06/11/2012 - 8:34 AM in Degenerative Disc Disease
I have been diagnosed with severe degenerative disc disease with 2 herniations , the worst at L5 S1. Nerve pain in my groin and down my right leg. Constant lower back pain made worse upon standing and leg pain worse upon sitting.

I went thru all conservative treatments (physical therapy, medications, epidurals, etc) over the last 3 years during which time I have been unable to work because I cannot sit or stand for over an hour without crippling pain.

I finally decided to overcome my fear of open surgery because I cannot live with the pain and the impact it has had on every aspect of my life. I saw several docs to ensure I made the right surgical choice. One said disc replacement (scary and not covered by my insurance anyway) and 2 said spinal fusion with discectomy... so majority rules and I chose this option.

I scheduled the fusion, made all preparations including suffering for 2 weeks off of some of my meds, only to be told 4 days before the surgery that my insurance would not pay for it because it is not medically necessary.

My surgeon requested a peer to peer review and they had a vascular surgeon call him...not a spine surgeon, so not a true peer to peer. I fought this and they said the only way to enlist a spine surgeon to call was to request an appeal, which I did. Now I have been told that the appeal was denied, but yet although a spine surgeon supposedly looked at my file, no call was made to my surgeon to discuss my particular case.

Now the insurance company is telling me I need to file a level 2 appeal and they'll get a conference call going with me and my surgeon or I can ask for the file to be sent to an outside surgeon, but that the decision of this outside surgeon would be final and I would have no other appeals.

First off, can they actually get away with claiming a peer to peer has taken place when a doctor with no training in spine surgery is the one who makes the call?
Secondly, does anyone have experience with this and/or suggestions on whether to do a levl 2 appeal or to roll the dice with an outside surgeon??? I should say that time is running out because the only time I can reasonably have this surgery is when my kids are home for the summer to aid in my care for at least the first 2 weeks. Help!


  • and welcome to the forum. You will find so much support and understanding here from our amazing members. I am so sorry to see that you are going through all of this and I truly wish that I had some advice to give on this particular subject , how ever , I don't....other than to say.....not to give up , keep fighting for your rights. Please keep us posted as to how you are doing and if there is ever anything that I can help you with then please feel free to let me know. Hopefully some members will be along shortly with some opinions for you. Take care.....Miki
  • I'm sorry you're having all these problems with your insurance company. Nothing is worse than getting all geared up for surgery and then not being able to proceed.

    I'm wondering if your surgeon's office doesn't have a surgical coordinator who can help shepherd this process, give you advice, since she's used to dealing with this all the time, etc.

    I used two different surgeons for my surgeries and I never had to deal with insurance. The coordinator arranged everything, and I understood it was her job to deal with any problems that might come along. Perhaps I was just lucky...but, maybe your surgeon has this type of person, too.

    Not very helpful...but just a thought.
  • I still have not figured out how an insurance company can tell you that you do not need a surgery that a medical dr that is qualified says you need, go figure, anyway I to never had to deal with the insurance crap it was all handeled for me, please check into that.
  • Hi, and I would get an attorney--at last resort. This is typical of Ins. Companies playing God. I just had back surgery last Weds. All was set up by the surgical coordinator. What does a vascular surgeon know about DDD anyway? I've had this happen before though, in the automotive collision industry. Some of this so-called professionals the Ins. Co.s have don't have a clue. I'd sue them if the second level appeal doesn't work. To heck with them (I have other words for them, but can't use them here).

    Decopression at L2-3, L-3-4, and L4-5, fusions at L2-3, L3-4 and at L4-5, pinched nerver roots fixed, (now my hipps don't hurt). The reason they fused my was L 3-4 was "lose" like a lose bolt. It had torn away from the ligament in there, so now I have 6 more screws in my spine for a total of 10.(4 in my neck from a fusion at C4-5 and 4 level laminectomy, all from DDD).

    I do have training in dealing with Ins. Co. in the automotive industry and they try to do the same things with that too. Ins Co's have power, namely money, and are anti-trust exempt, which is bull. It all comes down to the stakeholders wanting more profits--------
  • After if they deny you, then you go to the state level with the insurance commission. They will review it to see if you have a case and if you do they will send it to an outside reviewer and they will look at your records and make a decision. That is the final decision. Contact your insurance commission in your state, or go on the internet site for them. There should be the laws and rules governing this. Dont give up. I had to go through all of this and to the state. I won. PM me if I can be of more help. Good Luck. You can also contact your attorney for advice for your state. They will have the knowledge of what to do also.
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