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Insurance vs NS, round#1

JulieAJJulieA Posts: 1,420
edited 06/11/2012 - 8:41 AM in Neck Pain: Cervical
OK- Just so everyone knows (all the new faces). I was suppose to have C5/6/7 ACDF on October 19th, but my primary Insurance company denied the surgery and said I need 6-8 weeks of PT or "other" treatments before they would consider the surgery.

This is because the Pain Doctor who administered my EMG recomended Traction and Epideral Injections as well as anti-inflamitories. ....

At any rate I refused to have any epidurals but went through PT (got excused for extreme headaches). I still use the Tens Machine (not as often). I had another MRI Jan 7th right after seeing my NS again. The new MRI clearly shows that the herniations are much bigger- the axial views show the discs and osteophytes are completley clogging the foramin and laying on the cord with out any fluid. I am taking my pain meds around the clock now, and my hands hardly work. I have stopped my hobbies for fear of bigger problems as recomended by my NS. I use ice/heat and Norco/Flexerile almost constantly.

We have been trying to get the surgery pre-approved since Jan 8th, so that I can plan my work schedule (I am in outside sales and my performance has suffered much lately). I have food shows and sales meetings and my company needs to know so if I am off they can plan on sending people from out of state to cover for me etc (get the picture).

So today I finally get a call back from the lovely manager in the Insurance office. She stated she wanted to review my file before she called me that is why she was delayed. OK? I buy it. Then she says she hasn't recieved any paper work from my NS office at all since last year..... What? I just was told by the RN in the NS office that she had already been speaking with the nurse who reviews the cases in the insurance office..... OK. So there is nothing in my file? Right...... The office manager told me to have the RN from my NS call the nurse in the insurance office to get the ball rolling...................... I AM SO DISGUSTED BY THIS INSURANCE COMPANY.....

If you guys don't know- they had denied my PLIF. The NS reviewing my case was not a NS (they lied) he was a MEDICAL EXAMINER.

OK- I am done ranting now.



  • I would call the NS office today and talk to the nurse. Ask for the name of the nurse at the insurance company who she talked to and when. THen tell her you want a copy of all of your records for the past 6 months sent to you via email. Then I would call back the manager at the insurance company and tell her you are emailing the info to her directly since obviously they can't keep your info safe. (mention HIPPA and lost files and she will crap her pants)

    I would then tell her that you will be having your surgery in February or they will be getting sued for denial of benefits. You can also throw in how February is a slow news month and the network news is always looking for stories like this.....

    THey fight dirty so you have to also.

    Good Luck and remember the golden word - Hippa
  • Kris you rock! Thanks for the advice :)

    I actually called the NS nurse and she called me back yesterday (such a slow process). I said Maybe I should come down there and get a copy and send it certified mail? She said that wouldn't be necessary. She was going to call the nurse at the insurance company as soon as she finished faxing everything again. I am to call today to follow up.

    My Insurance Company said due to Hippa that nothing can be done over the internet.... They can not respond to any of my emails etc. They used to and Hippa was in effect when I had my last surgery.

    My NS will not schedule the surgery this time until it is pre-approved due to this being the second time my insurance co denied me. This is humiliating not to mention physically painfull... Maybe I should get a law suit going?

  • I'm glad you made some progress. What happened today?

    THere have been some recent changes to the HIPPA laws. THe internet excuse is nonsense. As long as they can verify who you are and you give permission they can certainly contact you via email. HIPPA is to protect your info from unauthorized access and now to allow you access to your info in a prompt manner.

    The biggest part of the recent changes is that you have a right to all of your records immediately. So the radiologist who says they will only send the report to your doctor is wrong. Your doctor has to give you copies of all papers he has immediately.

    I can't wait to hear what their new excuse is. The threat of a lawsuit is better than an actual lawsuit.
  • Nothing new today really. I called the Insurance Co nurse and it went to her voice mail. I asked her to please return my call as there was some mixed messages that I was getting from others involved. I asked her to please return my call and I was very nice.

    I called the imaging place to get a copy of the radiology report. At first the girl said she couldn't give it to me and then I asked for her super (who wasn't in). I asked her to have the super call me and 10 minutes later the girl called back and said "since I was so close to surgery that they would make an exception"... Right.... At any rate I do have the new report.

    Intersting since I went to a different nicer place. Newer equipment etc. He DX'd me a little different.

    He used the word "stable" a lot and I worry that my lovely insurance company will read something into it. He did a comparison over my last study.

    He says I have 2mm of retrololistesis on C5-6, focal sclerosis along the inferior c5 end plate is stable, likely a boney island or discogenic in origin. There is disc space narrowing at c5-6 with a broad based disc osteophyte complex and uncovertebral spurring contributing to bilateral moderate to marked neural forminal stenosis, stable compared to prior study. At the c6-7 level again noted is a small broad somewhat irregular disc protrusion measuring 3mm from base to apex. This impresses upon the ventral thecal sac and extends into the neural foramen resulting in moderate stenosis. Overal the impression is grossly stable compared to the prior study. No new disk abnormalities are identified.



    :O) :) :(
  • I think by stable he means that there is no change from your last MRI. Nothing new. I'm no expert but it sure sounds like you have a problem.
  • jlrfryejjlrfrye ohioPosts: 1,110
    Threaten to sue for pain and suffering due to the insurance companies run around they are giving you. Demand a expadited appeal. They have to respond to this appeal within 72 hrs. Demand to speak to a supervisor and do not give up until one is reached. Ask your surgeons office if they have a fax confirmation for your records that have been sent to the insurance company. Its time to get mean with them.
    Insurance is all a game unfortunatly and you just have to play it better, I fight with insurance companies on a daily basis (its my job)so if I can help in any way let me know. Feel free to PM
  • Julie,

    All I can say is stay on them. I have been trying to get a procedure paid for from last April and now I am rent less about it. Ask questions as to dates and times they will be calling. If they don't call you then call them. As far as your medical records you have a right to every single page of them. That is the only way you will find a discrepancy in them. A thought did occur to me that you could find a outside radiologist and have the films re-read by this person. I agree it appears the radiologist did a comparison study against the previous test. A problem with that is the insurance company, their expert, may not use the originals in the determination. Do you have second opinions saying you need the surgery? If not go get a second opinion the more evidence you have showing the need for surgery the more it will work to your favor. Hopefully soon you will get some answers. Take care and keep us posted.
  • Thanks gang.

    I will call again today and call the NS nurse again and see where we are at. The NS nurse says that she has all of the confirmations from the fax's.

    The second opinion the insurance took was from the results of the emg (pain doctor) who said I should have traction and epidurals. I probably should have a second opinion from a surgeon. They are so limiited here (Anchorage Alaska) that I would probably have to wait for several weeks. I will discuss this with my NS nurse today amd see of they have some one they use that mught be able to get me in quicker (it is a small town so everyone knows everyone).

    The MRI views that I have compared are from July & January look different to me (much worse hubby agrees). The reports are different but then again I had 2 different places.

    I think I need to pay a lawyer the $200 (or whatever he charges) to just write a threatening letter at this point.

  • The nurse at the Insurance Company called me back. I was driving and couldn't reach my phone it time. Darn it. At any rate. She said she did recieve the information this week and that she is sending everything on to the Medical Director to decide.....

    I will follow up on Monday.

  • JulieA said:
    The nurse at the Insurance Company called me back. I was driving and couldn't reach my phone it time. Darn it. At any rate. She said she did recieve the information this week and that she is sending everything on to the Medical Director to decide.....

    I will follow up on Monday.


    I have my fingers crossed that *this time* they will get their heads out of their @ss and let you get fixed and healthy! Keeping you in my thoughts and prayers woman!!! *HUG*

    PCTF C4 - T2, Laminectomies C5, C6 & C7. Severe Palsy left arm/hand.
  • I hope everything works out for you and you get surgery soon. I can't believe the power this Insurance company have with the shown evidence that you're not getting better and this is interrupting your ability to heal from the surgery whenever you get it. If the Surgeon said you need surgery now! I can't believe the Insurance has stopped this. I hope you're able to get surgery soon and start healing. I hope you have more answers Monday. Take care and good for you for your persistence it will pay off. 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
  • So I finally recieved a call back from the Insurance Co. I started calling Tueday, Wednesday, today.... She (the office manager) called me back. She said " we are sending everything over to the medical director since this is such an involved procedure and he will have a decision by Monday at 5 pm).....

    So last week when they were sending everything over to the medical director they must have gotten side tracked or decide to let it sit on the desk?


    She promised to call me Monday at 5 pm (I will believe it when I see it)... :(

    I did speak with my employer on Monday of this week. She said it was out of her hands at this point. I will update her tomorrow.

    EEGADS these people are driving me crazy. I would really hate to have a job there. Can you imagine never having anything good to tell your customer? I wouldn't want to talk to me either... No Mrs Alvarez there has been no change to your records (bc they find a way to misplace it or neglect to update it).... This reminds me of the movie "A Civil Action"....
  • Insurance companies are not in the business of paying out claims. Unfortunately like most of this country they have become so overloaded with employees and red-tape they don't have the money to pay benefits. If they got rid of all the crap they could save enough money to pay what their customers deserve.

    100 years ago you put in a claim. One person looked at it and made a decision. If you didn;t like the decision his boss looked at it and you were done.

    Now 16 people have to touch your claim before they decide to get a specialist involved. Then 20 more hvae to look at it. Along the way they lose papers and make mistakes that cause more delays.

    I was out of work for three weeks after surgery. I call the insurance company. They send a wage verification to my employer who doesnt get it the first time. I have to call the doctor to get a note saying how long I had to be out. Then I call the insurance ocmpany and they say they don't have the paper from my employer. I call him - he's working on it. Now a week later it still isn't done and I don't have the money. Five people to day I was out and god only knows how many more are involved in processing the check.

    I would start calling around 2 on Friday just to make sure the doctor is on schedule and will have an answer by 5. I bet the lady you talked to leaves at 4 - lol.
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