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Insurance problems for surgery?

AkSAAkS Posts: 13
edited 06/11/2012 - 8:42 AM in Back Surgery and Neck Surgery
At my next appt. with my neurosurgeon, I'm going to be talking about scheduling a cervical fusion. I'm at the point right now that I will jump through flaming hoops to get out of pain, and while I know that there is no guarantee that surgery will cure that, it's something that I do want (as soon as possible). My NS' secretary said that his OR schedule looks good and I would get in around 2 weeks from my appt, but I have read that many insurance companies deny the surgery at first. Is this common? This is from an auto accident, so everything so far is going through no-fault. Is it basically a 'given' that the surgery will be denied at first?


  • No, it is not a given, but it does happen, and seems to be happening more this year than in years past.

    I had a lumbar PLIF two years ago and had no problem. I was supposed to have surgery on 2 March...got a call on 1 March informing me my insurance was denying coverage for surgery.

    They seem to be cracking down more on artificial disc replacement and some of the newest methods of fusion. If there is clear evidence that the fusion is medically necessary, you should not have a problem...(hopefully!)

    Good luck.
  • I had a TLIF done on 2/2/10, which was originally scheduled back in November. My insurance company did not deny the surgery and then my employer had our health insurance changed to a different plan effective January 1st. Luckily I did not have any problem getting approved for surgery under the new plan and the surgery date remained the same.

    Good luck and hopefully everything will go smoothly with your insurance approval as well as surgery.
  • Thank you both so much for your responses.. I've been lurking here for the past few months and finally decided to make a username so I could join in. You have no idea how much help you all have been, unknowingly, just by offering your advice to others. I"m sure there are many more out there like me that don't create a username, so you never realize the lives you've touched. Pat yourselves on the back for me! You are all awesome
  • SpineAZSpineAZ WiscPosts: 1,084
    It's not that insurance companies deny on first request, we see that more when people are applying for SS Disability Benefits. Under health insurance denials are seen when there is not enough evidence for the insurance company to be confident that the requested surgery is necessary. And, often if that occurs it can be overturned in 24-48 hours as the surgeon's office will call the insurance company to see what they may need and/or your surgeon talks to the insurance company doctor to discuss why the requested procedure is needed.

    If your doctor has evidence to support the need for the surgery you should have no problem. I'm guessing you've been through the whole thing from x-ray to MRI, from primary care doctor all the way to neurosurgeon, and full review by the surgeon. And then the surgeon being able to match up your symptoms with the test findings.

    And, the staff in surgeon's offices often have a good feel of what insurance companies need and which patients will sail through the approval process and which may not. If the NS's secretary is already discussing scheduling options it's likely the staff feel there is little doubt that the request will be approved.

    I had a huge spinal reconstruction 2/3/10 and I was nervous about the insurance company approving me for such a revision. The surgeon's medical assistant called my insurance company and received approval the next morning.
    2 ACDFs, 2 PCDF, 3 LIFs; Rt TKR; Rt thumb fusion ; Lt thumb arthroplasty; Ehlers Danlos 
  • Yes, I started out with my primary, was sent to a neurosurgeon, then sent for MRI (herniations and minor bulges), back to neurosurgeon, then to physical therapy and pain management for injections, been with PT 3 times a week for almost a year, 7 neck injections, a second MRI, xrays that show my vertebrae are grinding against eachother at c5-c6, EMG/nerve conduction that show pinched nerves at c6 and c7, horrible pains and horrible headaches, and that is where I'm at now.
    I have a really hard time with pain control for some reason, I've been on vicodin 7.5/x?, ultram 100mg, tramadol 50mg (2 to make it 100mg)(guess they had the generic that time I filled my prescription), naproxen, and now I'm on oxycodone 5/325? (1 and one half pills) - sorry, I can never remember the second number.. anyways, now the oxy is starting to not cut it anymore, besides the dead arm feeling, although it burns like the dickens..
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