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3-Level Fusion Scheduled for Tomorrow DENIED

gwennie17gwennie17 Posts: 2,957
edited 06/11/2012 - 8:42 AM in Back Surgery and Neck Surgery
A number of members have been asking about my pending surgery. I found out today at 2:30 that the orthopedic management company hired by the insurance company to evaluate the necessity for spinal surgery has denied our request for a 3-level lumbar fusion. They called my surgeon's office and left a voice mail message that provided NO reasons for denial...just stated "Surgery Denied."

I know the decision can be appealed, but I am really devastated by this late date change in plans.


  • Howdy Gwennie,

    Am I understanding this right? Your insurance company hired your management team to decide the best course of action for your health. They decided that surgery is the best way to go, and the insurance usurped their own team? Incredible!!!!

    So sorry to hear this, even more sorry that they basically gave you NO NOTICE within reason to find out why in time to still get the surgery. What are you going to do? Wow..... *HUGZ*

    PCTF C4 - T2, Laminectomies C5, C6 & C7. Severe Palsy left arm/hand.
  • I'm sorry to hear that. I don't understand how they could cancel so soon before surgery. I hope the appeal turns in your favor and hope there's no further risk to you prolonging the surgery. Take care and hope you can get through this. Thinking of you. >:D< 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
  • Lord, if that doesn't sound like the work of some contracted bean counter! I'm sorry for you that you're getting the corporate cold shoulder. I'm also flipping your "management" company the bird. For the company just to call up and leave a little voice mail like that is chicken s&*$! It's obvious that YOU are the very last of their concerns.. I don't know if you can tell, but stuff like that pisses me off. I wonder if the suit that made that call would think different if it was their mom they were evaluating?

    Sorry for the speedbump in your way,
  • You must be absolutely floored. After getting yourself prepared, they cancel the day before? That is so wrong. Keep us posted as to their reasoning.

    Best wishes,

  • I'm so sorry to hear that. Especially the day before surgery, that's soooo unfair.
    Can they do that without providing a reason? Is there any way to call them and find out why?
    You poor thing. I'm speechless.
    My thought are with you.
  • sunny1966ssunny1966 VIRGINIAPosts: 1,385
    I can't even imagine the disappointment you're feeling. I'm sure you'd already made preparations for your recovery and everything. They could have at least given you more notice! I think it's a sad thing that insurance companies dictate what we need for our health. This just ticks me off! I'm sorry Gwennie. I hope you can have the surgery you need soon.

  • My wife said to get a lawyer. I agree it isn't right that they did what they did. I was worried workmans comp was going to do that to me cause they are so cheap. But they authorized mine before I left the dr.'s office back in Jan..
  • I cannot believe that the insurance company hires a company that is supposed to know about this stuff and they deny it. I think what is disheartening is that you and your doctor tried all week to find out what was missing and someone is too darn lazy to actually give you or your doctor useful information.

    I hope that you and your doctor can talk to the insurance company to find out what the heck they are denying it for...so that you can straighten it out and get back on the calendar.

    I will try to find the silver lining...it will be warmer weather and better for driving to/from hospital and follow up appointments.

    Keep us posted. Sorry to hear this news.
  • I am so so sorry for you. I thought I was the only one the got denied the day before surgery! It is so disheartning, maddening, and every other emotion you have in your body all at once. I remember the pit in my stomache when they told me, and how hard it was, I feel your pain. Just dont let them get by with it. No matter what it takes. I know that it doesnt make you feel better right now, have a good cry like I did. Then get mad and start showing them who they are messing with. I went the whole gammat. I had to go to the state appeal level. Then once I got that and did what was reccommended, they still wouldnt budge. That is when I called the Head of the states of Iowa and Nebraska for the company. Long story short, I got it approved, right away, with in network rates, even though my Dr was out of network.
    My heart goes out to you, and if I can help you, in any way, please let me. You have been there for me so many times. Take Care, My Friend, Brighter days are ahead! Love, Robin
  • :''( So Sorry Gwennie: You have to go to the Ins. Co. and have your Dr. argue in your behalf or go to the management co. and see if they will give you a definitive answer. Don't know if any measures will help...we all have to depend on some bureaucrat who knows nothing about medical care to make this kind of decision for us. DISGUSTING!!!! The whole ins. sutuation for almost all of us is ridiculous. I know that my Dr. won't accept Medicare and I have to pay him for the surgery up front; he won't accept Medicare. Medicare will cover hospital, etc. If anyone thinks that these situations will get any better if we have ObamaCare, they are crazy...it will only get worse unless you can pay yourself.

    I hope and pray that you'll be able to resolve this situation. Tahoegranny
  • Gwennie,
    I don't know what else to say!!Thinking of you.
  • I am so sorry, Gwennie! What an awful letdown, especially at the last possible moment. I hope you can get some answers, and more importantly, can get your surgery rescheduled. We're here pulling for you, just wish there was something tangible we could do. :( :confused:" alt=":confused:" height="20" /> Saying a prayer for you tonight.

    2009 Foraminotomy C6-72010 PLIF L4-S1Multi RFA's, cervical inj, lumbar injLaminectomy L3-4 and fusion w/internal fixation T10-L4 July 17Fusion C2-C5 yet to be scheduled
  • As you know Gwennie I have been praying this surgery was going to go ahead for you and my heart breaks to think of how you must be feeling right now, as every day is a struggle when your in pain and my prayers are that in the end you come out ahead and this will soon be behind you. Wishing there was more we could do to help but you do know your "spiney" family are here for you.

    With hugs
  • Thanks everyone for the kind words. I don't much feel like writing anything tonight.

    I'll be back after I regain my equilibrium.

    XXX gwennie
  • Sorry Gwennie

    I hope they get it figured out, I agree get a lawyer thats BS the day before to tell you. Praying for you.

    Take care ;)
  • I am so very very sorry this has happened to you :(

    L1 - S2 "gone" useless in 1 way or another. DDD. RA. Bone Spurs. Tons of nerve damage/issues. Stenosis. Both knees replaced. 50 yrs old. I had a great fall (hence my user name) at age 41 and it has been a domino effect every since.
  • Sorry Gwennie,

    I would definately call the insurance company first thing tomorrow and ask for all of your records to be sent to you immediately. I would also ask for the outside NS's credentials etc. They need to send you the denial letter immediatley also.

    This has happened to me 2 X's and ended in my favor both times.

    It really does suck ~hugs~

  • Do you have any tips on how I should proceed? Should I let my surgeon's office handle it or proceed on my own? Up until this point the insurance company has been great and covered everything...so this really was a big surprise.

    I think the problem is the multi-level fusion.
  • dilaurodilauro ConnecticutPosts: 9,846
    that, especially at the last minute. I am sure that has got to be real disappointing to you and makes you a bit angry.
    I hope something works out for you
    Ron DiLauro Spine-Health System Administrator
    I am not a medical professional. I comment on personal experiences
    You can email me at: rdilauro@veritashealth.com
  • I have had the same thing happen. You need to start your appeal right away. In the appeal your surgeon needs to write a letter explaining to them why you need the multi level fusion. Then you also need to explain why you need it, and everything you have done to avoid surgery. That you have tried PT for at least six months, even if it was "done on your own after instruction". The key to it is that you have tried eveything else with no help to your symptoms. When I did that, at the state level they lost because I had a discogram that showed the problem. I also had tried everything and PT for six months. The key being I had done some at hospital pt dept, and the rest self directed. The state appeal that was sent to arbitration agreed with us, except I had to have a discogram that was with recorded pressures and a blinded one. The first one didnt have recorded pressures. After the second discogram, there wasnt anything they could do, as the outside Dr in the appeal had said it the discogram had shown the problems, I needed it done. I had two levels done. I hope this helps. I just wanted to help you if I can. Love, Robin
  • I'm so sorry this has happened, especially the day before you were due to go into the hospital. It takes a lot to psych yourself up to undergo a big surgery like your's and then to get a voice mail to say it's been denied is crushing.

    Do appeal this because you can't keep going day in day out in heaps of pain with no end in sight.


    XLIF L2-4 20.8.15
    ALIF L4/5 2009
    Laminectomy/discectomy L4/5 2008
  • LizLiz Posts: 7,832
    I am so sorry to hear this has happened to you Gwennie....I am thinking of you and hope it turns out ok

    Hugs xx

    Liz, Spine-health Moderator

    Spinal stenosis since 1995
    Lumber decompression surgery S1 L5-L3[1996]
    Cervical stenosis, so far avoided surgery

  • Gwennie,

    How terrible - I hope that between your surgeon and your efforts you can get this straightened out and get the surgery you need.

    Hope you'll get good news soon.

  • to hear this!! Sounds cold and heartless. Hope you can get that appeal going quickly and sort this out. You must be so angry and disappointed.

  • with your bad news.
    Take some time to get over the stress of this, and then pick up the batton and start to get the appeal going.

    I would speak to your doctor and see what he says. I expect he is annoyed too, as he had you scheduled for surgery today. I also expect he has experienced this type of thing before, and will have ideas of what to do next.

    There are people on here who have had similar experiences and managed to appeal and get the refusal overturned. There is lots of hope that you will be able to do the same and have your surgery before too long.

    This is not the end of the story. Wishing you lots of energy for the fight up ahead.

    Take some time to spoil yourself.

  • What a nightmare!

    This happened to me. I was due for surgery on the Tuesday and on the Friday the insurance company refused to pay for it! I couldn't believe it either....I had prepared everything (time off work, my husband had rescheduled his diary for time off, I had arranged childcare etc etc).

    So after discussions with my husband, we were in a fortunate enough position to pay and continue with the operation on the Tuesday.

    My solicitor (lawyer) has now instructed an independant spinal expert to prove that the operation needed to be done and this was my last chance to help with my back (I had a complete disc replacement ADR). If the insurance company refuse to give us our money back for the op, we are taking them to court.

    It is a terrible position to be in and I wish you luck.
  • Dang, if it's not one thing, it's another. I know you are heartbroken with disappointment. I can handle almost any emotion but disappointment is the worst. I too recommend that you just take a day or two to get your mind right and to make some decisions on which route you are going to take. Believe it or not, this will work out. It's just going to be at a later date than you had planned. Get over the shock and then march forward. This is not the end. Keep that remarkable spirit of yours up and don't let this get the best of you. I wish you the best.
  • Gwennie,

    I am so sorry to hear this happened to you. As all the others have said it needs to be appealed. The outside company that has been hired, you might want to check and see if they reviewed the films or just the reports of them. We all know surgeons are looking for a particular thing on the films that often aren't in the radiologist report. Also you need to find out what is the treatment that are recommending being done in place of surgery. It maybe what they are recommending you have already done and it has failed. I deal with work comp and these companies are the same companies as work comp is using. Trust me I have seen the bills they charge for this so called expert opinion and they get a lot of money to say no. I agree with Julie you need to also find out what records they used to make this decision. Don't forget to get your surgeons records as well. There maybe some debate in his notes that he questions this decision, or written in such a fashion it gives the opinion of that. Hang in there while this is tough to deal with your a smart person and will be able to get the information. Oh don't let them blow you off by not answering phones and not returning calls. If that happens just go to the operator and ask for the manager. Anyway take care I know this is hard but hang in there.
  • I know that you are upset and disappointed, but you don't want to do or say anything that might cause a problem later. I would have the doctor's office call to find out what happened. They should make it clear to the insurance company that cancelling at that late date cost alot of money is lost use of the hospital and the surgeon, etc.

    I am surprised that the doctor's office hadn't gotten approval prior to scheduling. Something isn't right there.

    If the doctor's office doesn't get an acceptable answer then call the insurance company yourself. You said they have been good so far so hopefully they will continue that way.

    With some luck this will get straightened out very quickly and you can get rescheduled.
  • Gwennie....I am so sorry that you're having to deal with all of this. There really ought to be rules for the insurance companies on the amount of time they have before a procedure to deny it. The emotional cost of a denial so close to the procedure date is just wrong. You are a strong woman and have a family of spiney's that are here for you. Imagine the poor person who doesn't have all of that and has gone through the same "hyping up" just to get mentally prepared. THis is just wrong and there must be something that can be done to change those rules. I hope by now you've started your appeal. Gosh, I can't help but think that there are rules that apply to this. I mean, here in NYC if you cancel an appointment when there's less than 24 hours until said appointment, your doctor can charge you a surcharge for cancellation. If a dr can do it, why can't a patient and/or doctor's office do the same to insurance companies. This is crazy.

    I'm so sorry about this for you. It does break my heart. You're the source of great knowledge and encouragement to so many on Spine Health. I hope that all the posts on this topic can now be a source of encouragement for you.

    the clumsy one
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