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!