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Fusion Denied by Insurance

SlancastvaSSlancastva Posts: 43
edited 06/11/2012 - 8:42 AM in Back Surgery and Neck Surgery
Received a letter from insurance company today. My lumbar fusion for March 18, 2010 has been denied. It is an axialif. I reckon this is considered experimental. and OH, the letter also states there is no documentation of spinal instability. What a joke. I was at the doctor's Wednesday, he told me he had to call the insurance company and to call back Monday, but he did not tell me it was denied, he said the insurance company needed more information from him.

Well, thanks for listening. If the doctor cannot get them to change their minds, who knows. What will be will be. I cannot afford the fusion. I am a lot disappointed at the moment, but the lord will carry me through and find another way to help me. Just got to keep trying. (But oh there are times when I do not feel like it).



  • What kind of back problems do you have that they wont operate?
  • I had a microd. in March 09 for rupture disc. I have reherniated at L5/S1,DDD and severe oa in facet joints of lumber. I have went the conservative route for over a year. Lost weight, pt, nsaids, facet joint rhizotomy (Did not work).

    The reasons for denial are listed below:

    Treatment must be consistant with my symptoms,
    Treatment must be not experimental or in an investigation state.
    Treatment must not be furnished for the convenience of the patient or doctor
    Treatment must be furnished at the most appropriate level that is safe and effective.

    I believe they denied it because the procedures is only be around 5/6 years.

  • Man thats crap! I wish you the very best of luck! My consult is at the end of this month and I am pretty sure he will operate or he wouldnt have scheduled me cuz he had my ppr work for a month and they said he wouldnt even schedule me if he didnt think i was a candidate but the ins on the other hand I do not know but I have never had an operation on my back but have had wayyy too many injections and PT....What ins do you have?
  • By chance, does your doctor do MI TLIFs?
    I know many US insurance companies will not approve XLIF or ADR just yet unless you meet a very specific criteria.

    You have the option to pay out of pocket if you really want that route and then petition. I believe there is someone doing that for ADR.

    You may want to ask your doctor if he cannot get an XLIF approved, if he does MI TLIFs and if that is an option.

    That totally sucks but I think you are right about what's causing it.
  • Alot of times it can be because the doctor didn't get in touch with the insurance company and give them all the revelant info, bascially being lazy. Not lazy but doctors get so busy they forget. I would talk to your doctor.

    Good Luck ;)
  • I had Axialif. It is not experimental. It is new for many surgeons. Mine has been doing it for at least 3 years. I had previously had a microD at L5/S1 for herniated disc with tear. Shortly after surgery I got in an MVA. Result was it caused micro to fail. Axialif was what my neuro wanted to do on me. I'm 4 months out and it is working. He had no problems getting it approved.

  • almost every fusion is denied the first go around. The are expensive and some people will not appeal. My attorney gave me the statistics of % at each level of appeal. I had to go to the state level, which most people, he said only around 10% will go this far. It is then that a Dr that is not for either side can give the decision. I won, and I urge eveyone to try. It does not cost you anything except the filing fee for the state to review you file and deem it necessary to go to the outside source.
    Inusrance companies try to bank on people giving up, I swear. I got denied the day before my surgery. It was the most devistating thing they can do to you. But I turned it around and want going to take no for an answer. I had no choice. I was in so much pain.
    So Sharon, DONT give up. Fight for your rights. You pay for your insurance to give you the right to get treatment for pain and illness. I hope that you can get this resolved. Sincerley, Robin
    PS I will get off the soapbox. I just get so angry looking back at what they put me through, and now I am facing another possible fusion. Hate to start the fight again...
  • I do not make a habit of correcting other members, but in this case, ZO6 is incorrect in stating that AxiaLIF is not experimental. I know for a fact that some insurance companies do consider it an unproven surgical procedure. You guys must have different insurance companies!!

    If I can find documentation for this, I will post it. I just read it a couple nights ago as I was researching my own denial!!

  • SpineAZSpineAZ WiscPosts: 1,084
    As Gwennie said it is VERY common for insurance companies to deny coverage for Axial LF. While the procedure itself is not as experimental as it once was, it is more along the lines of the insurance companies have not seen success (short term or long term) of this version of a fusion. So they don't feel they have enough data to consider it an acceptable risk and acceptable treatment. From what my doctor said they have seen some nerve damage from Axial LF procedures, not even involving the nerves you may have that are hurting you now, but nerves they disrupt upon entry via Axial LF.

    There are two questions in your case (1) Axial LF approval (2) Fusion approval (if other method is used). It appears Axial LF is out of the question. So part 2 has to be addressed.

    I've heard of many insurance companies denying fusions. Unless there is known instability of the spine (i.e. spondylolisthesis, recent accident, broken vertebrae, scoliosis, etc) the insurance company is looking for medical information to substantiate that a fusion is the right approach to your specific spine problem.

    There are many studies/publications out there that show that at one time fusions were being done in mass numbers, but there was a large number of patients that had no positive outcome (not that they were harmed, but it did not help). Thus insurance companies have become more careful at reviewing requests for coverage of fusions.

    Recently I have been in touch with two people who had recent denials. I will give you the advice I give to everyone in that situation: Before you attempt any appeal on your own, contact the key staff at your surgeon's office. This can vary, it can be a Practice Manager, Nurse, Physician's Assistant, Medical Assistant, etc). In my case, my surgeon has a premier Medical Assistant (I have had over 20 surgeries in 4 states since 1982 and she is by far the BEST office employee of any surgeon I've ever seen). She starts the fights for approval, works with insurance companies to see what more can be provided to them for review, and arranges for "physician to physician" calls in which the surgeon has a scheduled call with the insurance company doctor to discuss the case. In the two recent fusion denials I've heard of at least one has had similar staff in their surgeon's office with success resulting in surgery approval.

    Sometimes it is as simple as the insurance company doesn't have a key document or test finding. Sometimes it really requires a conversation between the surgeon and/or office staff as to why a fusion is needed.

    I can tell you that I recent had a posterio-lateral fusion. The did a posterior incision (6" vertical incision down my back since this was L3-S1) and a 4" incision horizontally on my right hip (that's the lateral portion) which was used to access the front of my spine. I had checked with my insurance company via the internet prior to planning surgery and their guidelines disallow Axial LF in all cases. And they are a major US health insurance carrier.
    2 ACDFs, 2 PCDF, 3 LIFs; Rt TKR; Rt thumb fusion ; Lt thumb arthroplasty; Ehlers Danlos 
  • I battled with getting my surgery covered when I didn't have health coverage. I live in Oregon and qualified for their basic public health coverage, but the hospital I went to had to cancel my surgery because my condition was coded as "clinically insignificant spondylolisthesis" and nobody would change it. Despite the fact that I had a screw loosening from my failed PLIF surgery 3 years ago and had very obvious pseudarthrosis. My pain has become unmanageable. There is nothing "elective" about the ALIF I need.

    I just turned 27 and have been dealing with chronic pain for more than a third of my life. I finally ended up marrying a friend so I'd have good health coverage (Kaiser) Yeah, it got to that point, which is REALLY sad. The folks at Kaiser haven't given me one ounce of objection to the ALIF I need. Which is pretty ridiculous that it was that easy for them and such an overwhelming ordeal for anybody else.

    Try and stay positive. I know how frustrating it is and it's easy to feel defeated when you're living in pain all the time. Hang in there and keep fighting your insurance for the care you need. As others have said- look into what specific kind of documentation you need to have your surgery approved. Mine was initially denied simply because of the medical code. If one doctor had changed that, I could have gotten my fusion done two years ago. It's pretty infuriating that it had to happen like this, but I'm finally getting the care I need. Stick with it! I've spent my entire youth with a severely injured back and it's been a RELENTLESS battle. But I think it's finally going to be okay now. Ultimately it was worth the fight. I'm sure you'll find it to be the same with you as well.

  • Thank you all for the support. My insurance company is a major one also. Anthem BCBS. It could be something as simply documentation or the insurance company needs more information. I don't know, I still believe it is because the procedure has not been around long. I will call the doctor's office Monday. I thank you all for all the suggestions.

    It is sad I might have to start over but I tell you feeling sad and crying does not help my pain or spirit.

    Sometimes, I feel so ashamed of myself, because there are other people who hurt or sickier more than I am.

    Hugs to all.

  • Sharon...there is no shame in being sad or crying. It's not about who has it worse or better than you. You are in pain and dealing with fear of surgery and now denial of the surgery that might make you feel better. Don't ever apologize for how you feel.

    We have all been there. It's not easy.
    You are so brave to say you are ashamed to feel sad but it's ok. You sound like you have a good plan for Monday's call to doctor and insurance company.

    Like I said, if it's the procedure, there are other options...Minimally invasive TLIF for example might be an option. Keep us posted!
  • Well my neuro says it is not experimental. However the insurance company gets a free out for many years on anything new. There are several studies done on AxiaLIF. Different insurance companies allow different things. You're splitting hairs Gwennie. I have reports that say you are wrong. Anyone can scour the internet to find an opposing view. You seem to live on it reading this stuff. This person is getting denied with the same excuse you got. Your case documentation has holes in it and the insurance company walked through them.

    My insurance company is probably the largest provider of private health care. They are not part of BC. I had the option to get insurance with BC at a lower cost and passed on the offer for several reasons. I have never been denied anything, with 1 exception, no ADR on any level. They have 1 or 2 more years to balk on it before the timer expires. They still use the excuse "experimental" and we know that is bull...

    SpineAZ. Very common. You got facts to back that up? Do you work for an insurance company? Sounds like you see this issue. Is it just 1 company that denies it? Because the major private HC company I use approves it. I also had the option of TLIF. You state that there is possible nerve damage from AxiaLIF approach. That's correct. Angle of entry and not hitting a specific organ is critical. Do you think you took no risk with your surgery? Being accessed from 2 sides of your body? Your risk was much higher than mine.

    Sharon good luck with this. I hope it is really a matter of your surgeon providing documentation in a format BC likes. When my mom had BC they denied claims regularly. We moved her to another insurer and the problems stopped.

  • Graham -- You are being overly defensive. All Spine Az and I are saying is that some of the major insurance companies in the US do not cover Trans 1 Axialif, and a couple other newer procedures and it is stated right on their online coverage.

    I won't bother linking to all I can find, but, here is one from Aetna:

    "Aetna considers axial lumbar interbody fusion (AxiaLIFTM), a percutaneous pre-sacral access route to the L5 - S1 vertebral bodies for spinal fusion, experimental and investigational because of insufficient evidence of its effectiveness." (taken from: http://www.aetna.com/cpb/medical/data/700_799/0772.html


    "CIGNA does not cover ANY of the following surgical techniques/devices used for lumbar fusion because each is considered experimental, investigational or unproven:
    • anterior interbody fusion or implantation of intervertebral body fusion devices using a laparoscopic approach
    • pre-sacral interbody approach, including axial interbody approach (AxiaLif®)
    • extreme lateral interbody approach (XLIF)
    • dynamic spine stabilization device systems (e.g., Dynesys® , Stabilimax NZ®) "


    Similarly, you can find articles in the medical business journals that point to a loss in projected profits for Trans 1 due to reluctance of insurance companies to reimburse surgeons for using Axialif.

    I am delighted that your company covered the procedure. But, just maybe your insurance company is the exception rather than the rule. I was only pointing out to Sharon that I have run across a number of big companies that state right on their websites that it is not covered, and that MIGHT be the reason why Sharon might have received the denial. I thought it would help her to be prepared when she calls tomorrow.

  • SpineAZSpineAZ WiscPosts: 1,084
    Yes, there was risk in mine as I had posterior with a little lateral. And I do have some nerve pain from the lateral that is in my groin and thigh. It's not major and the neurontin helps. With my fusion I'm still in bed nearly 20 hours a day some days so I can handle pain, etc.

    And since you asked......right now I am on Long Term Disability but have worked in insurance for 20 years. Worked in many states, in many capacities (including low level and high level) for many major carriers. What I was saying was coming from the perspective of having seen procedure approvals, denials, trends with insurance companies, etc.

    Insurance companies see both risk and lack of long term outcome studies in order to support the procedure. It is more "Investigational" at this stage. In simple terms they are scared of it not working, causing more problems, etc.

    There was a time, over 20 years ago, where laproscopic gallbladder removal was denied by some of these same insurance companies for the same reasons, while now they encourage it. They needed to know that it was proven and worked before it was permitted as an approvable procedure. (And I thank goodness my gallbladder removal was after that debate and I got mine done laproscopically).

    From a spinal perspective years ago there was IDET. It's still around, but it was highly encouraged by WC carriers until the longer term outcomes showed that it didn't provide the anticipated relief and repair. So it still exists, but is less common.

    I think Axial LF will continue to be re-debated by insurance companies over time. And as you can see there are many health insurance companies who consider it investigational. Believe me, if in the end it is successful and costs less in terms of procedure and hospital stay and "down time" it will eventually make it's way into the "approval" side of insurance company protocols. And there will always be guidelines under which they'll allow it so there's still room for making sure it's the right procedure for the right person.

    I'm sorry if you took any of what was said as something that upset you. But I just want to provide information so people understand that these things that happen aren't random. They are just what's going on in insurance today.

    2 ACDFs, 2 PCDF, 3 LIFs; Rt TKR; Rt thumb fusion ; Lt thumb arthroplasty; Ehlers Danlos 
  • Hey there,

    Not upset with you at all. No apology needed. I just saw comments in the above posts that I felt are misleading.

    Sorry you are having a rough time on recovery. My AxiaLIF does have an easier recovery. I think I spent 20 hours laying in bed for maybe 3 days tops.

    My concern was the wording sounded more like. If you get AxiaLIF there is a chance of nerve damage or hitting organs unrelated to fusion. It read, to me, like only with this surgery. I think we both know that TLIF, PLIF, ALIF all have risks. Newer people may not follow that reasoning. One thing I learned from my 1st surgeon when I got a microdiscectomy. HE told me my worst fear should be a surgeon with a scalpel. That if I let them cut into me there is risk of damage. Many organs and most certainly nerves and muscles are in the way with any entry approach. You have to weight in all the risks and your belief in your surgeon. Then choose and move on.

    My other concern was taking AxiaLIF, XLIF, etc and labeling them "experimental". That is not true. They were experimental before getting FDA approval. Your comment about "investigational" makes sense. I most certainly agree that insurance companies would back away from anything that doesn't have 10 years of proven track record. You're point is well taken. They are afraid to just jump on the bandwagon. Fortunately for many of us, and progress in general, I'm glad some insurance companies are willing to take the risk on surgeries that are "newer" without 10-20 year studies.

    The other part of your comment in my mind rings the most true. "If in the end it is successful and costs less in terms of procedure and hospital stay and "down time" it will eventually make it's way into the "approval" side of insurance company protocols". This is the bottom line. $$$. Like any other business it is about the bottom line first. Some think insurance companies are responsible for putting the patient first. They see it in the commercials. I used to work for a very large WC company. I'm quite certain that the patient does not come first. That, of course, is my opinion and observation.

    Good luck recovering. Hope you can get out of bed and off LTD soon.

  • I have Blue Cross HMO, and just had the AxiaLif 2 level on January 25th. I never heard one thing from them before or after. Not sure I understand why you were denied.

    The surgery itself did cost over $137,000.
  • I too need the axialif but mine is a 2L (double fusion)

    My nuerosurgeon informed me it may be denied, but about to put the paper work in this week and see what happens. the surgeon told me this surgery (axialif) is still considered to be experimental by most insurance companies, as you had thought, because it has not been around a long time and the long term effects are still not known.

    my problem is, this is my only option. As I competitive bodybuild, I have too much muscle for the surgeon to cut thru and would cause more problems then good. I will keep you updated and see what "IN-HUMANA" has to say about it. Luckily my wife is with proctor and gamble and they tend to do anything we want.
  • SpineAZSpineAZ WiscPosts: 1,084
    In regard to Jason being lucky enough to be approved by his BC/BS HMO. Just to keep it all in perspective.............

    Keep in mind that each insurance company sells thousands of different insurance policies. So you and your neighbor can both have an Aenta PPO but have vasstly different coverage, costs, etc.

    When an employer is purchasing health insurance and is looking to cut costs they often end up adding restrictions, limitations and exclusions (for example: excluding investigational/experimental treatment, excluding all cosmetically based procedures (differentiating them from medically necessary plastic surgeries,limiting the types of procedures allowed for a condition, etc.

    Using the example where you and your neighbor both have an Aetna PPO. You work at a large corporation that has chosen to limit your premiums, out of pocket costs, etc. Your neighbor works at small employer with under 50 employees and thus the costs to the employees are higher as their isn't as large of a pool to cover the risk.

    So your back surgery may be approved immediately and cost you $1,500 out of pocket. Your neighbors back surgery may be initially denied and require appeal and cost him $5,500 out of pocket.

    And, many BC/BS are independent of each other. Thus they can have different rules, structure, administration, etc. So Anthem BC/BS can do things differently than BC/BSTX (Texas based BCBS)

    2 ACDFs, 2 PCDF, 3 LIFs; Rt TKR; Rt thumb fusion ; Lt thumb arthroplasty; Ehlers Danlos 
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