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Update on Gwennie's denial~

gwennie17gwennie17 Posts: 2,957
edited 06/11/2012 - 8:42 AM in Back Surgery and Neck Surgery
After waiting two weeks to speak to my surgeon about the reasons why my multi-level fusion was denied, I went to see him today. We had a 45 minute conversation and I left feeling much better about the situation.

Then I came home and got on the phone with my insurance company. Things went downhill from there! I'll spare you all the details but what some of you may be interested in is that a number of insurance companies are becoming more finicky about authorizing fusions. They are using what is known as the Milliman Care Guidelines, which basically state that in order to qualify for fusion there are several conditions that must be established.

I won't quote the standards but the reason I was denied is because I didn't have a spondylolisthesis that was great enough to suit them and they did not feel I had demonstrated proof of neural claudication. When I told the woman I had two EMGs from different neurologists that stated I had chronic radiculopathy at S1, she told me they didn't pay much heed to EMGs because they were "subject to interpretation." I told her so were MRIs...that they do not always reveal what is wrong with the spine, and it was up to what the radiologist chose to emphasize about the MRI. She tried to tell me they could only make an evaluation on the information that had been supplied....We went back and forth for awhile, mainly over procedural things, and all in all, it was an upsetting conversation. I was left with the impression that it is not enough to meet the standard's criteria; you also have to prove it in a way that they find acceptable...but, so far we haven't had any luck finding out exactly what makes up their criteria.

My insurance policy says surgery is covered. It doesn't go into detail about how it has to meet particular criteria that are established by a team of actuaries and that this has precedence over several experienced surgeons who actually examined me!!

In addition to denying the fusion, they would not allow a decompression surgery instead, for similar reasons. I was basically told "you do not meet our criteria." We went round and round over what that meant, as it turns out, so has the woman in my surgeon's office. She hasn't gotten anywhere either!

I know Humana, Aetna and Cigna, among other large companies are all now using this criteria. I mention this so that if any of you have insurance through one of these companies,you will know to do what you can to clearly establish the reasons why the surgery is necessary.

I still have two appeals. I have not begun the first one yet because it has taken two weeks to find out WHY I was denied in the first place. I feel reasonably confidant that I will prevail. If not, my instability is bound to get worse.... @)

I've never had a bit of trouble getting anything covered previously. I thought maybe it was because we were requesting a 3-level fusion, but that is not the case. They refused fusion and they refused laminectomy.

My surgeon said he is noticing an up-tick in denials. Since mine two weeks ago, he has had two additional. I wonder if this is a harbinger of things to come?

I urge you all to keep copies from every appointment, get records from every imaging test you have done, any treatments, etc. Keep a paper trail if you think you might ever need surgery. Get copies of all MRIs -- it is easiest to request a copy at the time of service.

So, this completes this episode of my on-going soap opera. Stay tuned for the next spellbinding installment.

xx Gwennie



  • gwennie---I am so sorry you are going through this-it just %^&*(( me off when I think of someone sitting up in an office somewhere deciding our fate---I am praying for you-love,Jeannie
  • I wish you the best in your pursuit for getting your surgery approved. Insurance companies are so frustrating to deal with. You are a smart woman and I am sure you gave them a run for their money today. I only had Grade I spondylolisthesis, but it was my horrendous symptoms that swayed my NS to do my fusion. I can't imagine how I would be if my insurance company had denied my surgery just based on a number.

    Good Luck,

  • So sorry you had to wait for two weeks just to get frustrated by Ins Co. I know how it feels. I too had the refusal from ins co based on not meeting qualifications. I went through all appeals and prevailed. It was all about going through the external review, and having an disinterested party tell them if the discogram was redone, with recorded pressures, I met qualifications.
    So swiftly go through Co appeals, and take it to the state ins comm for external review. They look at things differently than Ins Co do.
    Is that a good enough Rah Rah Go Get Em speech for you? I hope so, I want to give you all the hope I can. Take Care, Robin
  • I think the insurance companies put the bottom line before your health. No brainer there. However, that doesn't make it stink any less! It sure seems like the word of your two trained doctors (who actually laid eyes on you) might outweigh the decisions of a panel of actuaries. I wish you great strength in your fight. Sounds like you're gonna need it.

  • Damn sorry to hear that Gwen. Keep after them, I know you will prevail. You know wayyy to much about the spine and your condition. :))))

    I had a neurologist appointment for early April and got a call that the Neurologist cancelled my appointment saying he cannot help me and that I need to see a neurosurgeon or pain Mgmt Dr. :(

    Today must just be a bad news type of day.... Hang in there.

  • Hang in there Gwennie! I am so sorry you have to go through this and I truly know how frustrating it is to have someone behind a desk determine your future!

    We are all here to support you! Sending prayers for strength, courage, and patience your way! Hang in there I know you can do this! Shari
  • hi gwennie
    so so sorry your going thru all of this..this is just horrible how can they deny request for surgery they are not medical experts..
    how sad you have to wait and go thru this stress
    i'm truely sorry..
    things have to be done with insurance co.
    mine will pay for pt for me to go get u/s massage treatments but will not approve a tens unit..
    they will pay up to 3,000 for pt a yr but wont ok a few hundred dollars.
    hope you get your apeal won quickly
    neck,bone spurs pain started 04, back issues and fusion l4,l5 06~hardware removed.
    good few yrs. 09 pain sharp, numbness feet,legs, diagnosed fibro, neurop. legs.lung issues.
    daily goal do good thing for someone.
  • Hey, not surprised. As others said, it's about making money and they are using actuaralists/statistcs whatever to make 'profit/loss' decisions.

    I am glad you are posting to make others aware of how to prepare. I will 2nd the "get a copy of your records". I've been asked 'why?' we have them on line. I tell them, thanks but I never know if I will move and/or if I get hurt the Ambulance won't take me to a hospital that has access to your records and I feel safest if I have a copy.

    Typically, you can sign a release to ask for a copy of
    - all your doctor appointments doctors notes
    - operative notes
    - release/discharge notes
    - radiology reports and images

    It's worth doing.

    I have to clean mine up but I have everything from my ER hospitalization back in August up to pre-op of 2nd surgery. I will be sure to get all my information on my recent surgery after I'm cleared for this very reason.

    It's a papertrail they hope you won't track.
    I treat my medical records like the IRS tax records.

    You will appeal and get through.
    If you have to contact your state rep, do so.
    The state doesn't want you on welfare or disability so if it comes down to it, they will fight to get you the surgery.

    I'm so sorry you are still battling but you are chipping away with each meeting and phone call.

    Stay tough!
  • Yeah, I have all of my notes/surgical reports/Mri's etc... I'm pretty meticulious about it. I have them in a binder and It's pretty full. That's sad isn't it?
  • Thanks, everyone, for your support. It means a lot.

    When my surgeon came into the exam room today, he was carrying a stack of papers about 1 1/2 inches thick...pointed to it and said it was all from trying to get insurance approval.

    His one comment was that he is getting really sick and tired of everyone practicing medicine without a licence and telling him what he can and cannot do. I'm afraid this is just the tip of the iceberg for all of us who are spoiled here in the US.

    On another note, I suggested to him that my nerve pain symptoms were changing and were somewhat different from the last several years, and perhaps I should get a new MRI. He wrote the orders, and I will be going in Monday. Hopefully it will show some new things....

    Oh, and one more thing regarding records...when I was talking to a nice, helpful person at my insurance company one day last week, I had sent one somewhat cryptic email to no one in particular, which I never got a reply to...but I found out that they had a copy of it in my file! The helpful guy told me we could do everything online and did I want to switch so that all my correspondence came online? I told him that I needed everything in writing because I wasn't sure that email correspondence would hold up in a court when I sued to get my surgery approved.

    Again, my point is that it's great to do things online, but sometimes it is important to have paper copies of correspondence, etc. You never know when you may need them!!

  • I am sorry to hear about your battle over approval. Of anyone though, I believe you will find a solution and be able to move forward. Your tenacity and strength will get you where you need to be. Surely if your surgeon is confident that the fusion is in your best interest then the insurance company will too. I hope it is just a matter of getting the right data in front of the insurance company. Stay strong.
  • I'm sorry to hear that you are still having a problem with your back. I don't know if you remember me.... I had the microdiscectomy 2 times on L5-S1 last year that left me with permanent nerve damage. I am doing the trial Implanted nerve stimulator now ( it will be taken out tomorrow) It has been wonderful!!!! I have Humana Insurance and we had to fight with them to approve the trial unit and now will have another round to get the final one placed. Has the stimulator been an option for you at all?

  • Gwennie, I so sorry to hear what you are going through with the insurance. I WISH our legislators would get a clue. An actuary as defined in the dictionary: ac·tu·ary
    1.Insurance. a person who computes premium rates, dividends, risks, etc., according to probabilities based on statistical records.
    2.(formerly) a registrar or clerk.

    And to top it off becoming an actuary is the #11 top college degree. So insurance companies pay more in those peoples salaries than it does for most patients care.

    How dare a clerk decide what care you require!! I am always astounded by what some insurance companies do to their insured. I wish you all the luck in the world dealing with supposed requirements. Funny they cannot describe their requirements.

    You gave great advice on medical records. Keep them people. I too have a binder.

    Keep after them!!!
  • dilaurodilauro ConnecticutPosts: 9,865
    always as being the 'black knight' as being described here.
    Sure, there are problems with our Health system, here in the USA as well as other countries Health systems.

    Insurance. Just take a step back about 15 or 20 years. Insurance premiums were a lot less and the idea of pre-certification and reviews really did not exist.

    Some of the reasons that began to change was because of the increasing number of law suits initiated by patients against their doctors and/or hospitals.

    Now here we are today and the rules are stricker and approvals become tougher.

    The way to ensure you get the appropriate treatment

    - Keep accurate records
    - Maintain CD's for all of your MRI's and X-Rays
    - Request medical records for all of your major visits.
    - When using online methods, make sure you include delivery and read receipts for all correspondence.

    Insurance companies are not the enemy. They are just operating under guidelines imposed by the laws of the Health systems.

    I have heard repeatedly for those in the medical field that so many 'denied' requests would never happen if the patient did all of their homework from the beginning.

    I am sure each situation is different and I can not say if one case vs another is right or wrong. But today, the emphasis on making sure you get approvals rest on us, the patient.

    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
  • Sorry to hear that you are still having troubles, I was kinda hoping it was some "clerical" error.
    Know that you are in my thoughts every day. You are always there for the rest of us, now it's our turn.
    Lean on your Spiney friends whenever you need to, were right here for you.
  • What I think I am seeing is a general crack down on unnecessary back surgeries. The increase in spinal surgeries has been quite astounding in the US in the last ten years, statistically speaking. I think with all the focus on healthcare lately, insurance companies are re-examining their criteria for various surgeries. I have noticed that more and more companies are using this Milliman care guide which has very specific criteria for surgery.

    And, anecdotally, surgeons are reporting more initial denials.

    I'm not quite sure how I can meet these guidelines as one criteria is neurological claudication...but they won't accept an EMG test result as proof! I guess that's what the appeal is for -- when you fall outside the specific criteria.

    All I know is I am spending a great deal of my life on the phone with various people connected to the insurance process!!
  • I am facing the same insurance nightmare. I was supposed to have discogram on Friday. The last time I had fusion, they wouldnt accept a non weighted one. So I had to go through appeal on it. Then after I went through the state appeal, that Dr said if I had a weighted discogram, I would definitely need fusion. So I had the weighted one.
    Now, we are going for the weighted one, to avoid the appeal from that, in Mpls, as there is no one in Iowa that does them. Now insurance company is giving the run around about it being out of network. Which has a 10,000 ded. But since no one does them in Iowa, Not even U of I, I have to go to Mpls. And they have to pay in network, as there is no one in Iowa. Geezzz , I cnat figure out which way they want it. They set the precedence with the last go around. And I have the documentation to prove it. ARG
    It is so frustrating! Good Luck wih yours, hang in there. Im thinking of you. Take care, Robin
  • Read your comment about the amount of back surgeries....It's so true. Here in Reno one of my Dr.s told me that more back surgeries are performed here than any other procedure, so it's no wonder that the insurance companies are making us crazy.

    Hope it all works out for you.

    BTW, my Dr. won't accept Medicare anymore and I have to pay him out of pocket and hopefully get reimbursed from my tertiary ins. carrier. I've had this happen before and my poor husband gets stuck with all the paper work. Sometimes it takes months to get it resolved sometimes even longer.
  • with the insurance company!

    I am so sorry you are still dealing with all this and i do pray you will prevail and get your surgery in the end.

    I too am fighting with my insurance company over a different test but its got me going around in circles and getting me no where. No point in getting into the details but I can understand your frustration, as insurance companies just don't seem to budge!!

    Hang in there, stay strong, and keep fighting!!!!!

    Good luck with your MRI,
  • I too was denied a fusion by Aetna. Their reason was that "Spinal Fusion is considered experimental as treatment for DDD" Within 48 hours of denial my surgeon did a peer to peer telephonic meeting with Aetna's surgeon and explained why I need this fusion (treatment for failed ADR, this is our last chance to fix this level) and was able to get it approved.
    Last year I had Cigna and had no problem at all getting an ADR approved the first time. I don't understand that at all as ADR is still relatively new in the US.
    I really despise the fact that it is up to these insurance companies to decide whether a specific treatment will work for us or not.
    Don't give up Gwennie, keep fighting and make them cover this for you. They have to understand that each case is different and they have to treat them as such.
    I am wishing you the very best in your fight with the insurance company, don't give up...fight the good fight!!
  • SpineAZSpineAZ WiscPosts: 1,084
    I am so sorry you are still going through all this. I truly hoped you'd have an outcome like Pammie did and by this time you'd be well on your way to surgery.

    I've had some neck problems and may need C4 added to my fusion. I told my doctor that if we find I need it let's go for it ASAP based on the direction of surgery approvals turning into denials!

    Let me know if I can help in any way as this goes along.

    2 ACDFs, 2 PCDF, 3 LIFs; Rt TKR; Rt thumb fusion ; Lt thumb arthroplasty; Ehlers Danlos 
  • I'm sorry you have to deal with this nightmare. It causes a lot of concern and I could foresee the insurance companies denying surgeries left and right. But I know that you are the one to beat this and win your appeals. You can do this. Hang in there....Hugs, Meydey
  • j.howiejj.howie Brentwood, Ca., USAPosts: 1,730
    I've decided to just wish you luck and send you prayers.To voice my oppinion of Insurance companies realy wouldn't be in the best interest of this site! Although ,I do have plenty! image:)" alt=">:)" height="20" />
    good luck, Jim
    Click my name to see my Medical history
    You get what you get, not what you deserve......I stole that from Susan (rip)
    Today is yours to embrace........ for tomorrow, who knows what might be starring you in the face!
  • Aetna, Cigna, Humana, and some other companies are all using the same rule book as of Jan 1st and the criteria for fusion are very specific. You would not get ADR approved now.

    Reasons for fusion are:

    Spinal fraction with spinal instability and/or neural compression.

    Spinal repair for dislocation, abscess or tumor.

    Severe degenerative scoliosis....progression of deformity to greater than 50 degrees with loss of function

    Spinal tuberculosis

    Spondylolisthesis with ALL (capitalized) of the following:

    High-grade (50% or more anterior slippage)demonstrated on plain x-rays

    Neurogenic claudication symptoms from lateral recess or foraminal stenosis

    Significant functional impairment ****

    Did you see that you must meet all three of these criteria. Just what is "significant functional impairment" and WHO decides??? This strikes me as their ace in the hole to be able to deny authorization at will.

    I was told I did not meet the standards for neurogenic claudication or radicular pain. I told the woman I had two EMG (nerve conduction studies) reports, one from a neurologist, the other from a physiatrist, both stating I had chronic radiculapathy at S1...that the surgeons used to tell me I had radiculopathy....She told me that they didn't accept EMG reports as they were subject to interpretation.

    I feel like I'm having to play their game on shifting sand. They keep changing the rules on me, or so it seems.

    My surgeon had a physician to physician contact call too...finally. They missed the first three appointment times but finally their doctor called on the 4th previously set time. They talked a half hour and my doctor said their doctor understood what he wanted to try to do and why...and he said the surgery would be approved. That was a Thursday night....we heard nothing....Finally, Monday afternoon at 2:30 there was a message left on voicemail stating my surgery was denied. (Surgery was scheduled for 9 the next morning.)

    My surgeon has been trying to find out why ever since. As close as either of us can come is "I didn't meet the criteria" and it was not "medically necessary." None of this was spelled out in our policy. My policy says it covers surgery....

    I know they just want me to give up...Well, that isn't happening.


    Thanks to everyone for you support and kind words. I really appreciate it. :)
  • Well , now that we have "health care", I wish everyone good luck with trying to get your surgeries approved by the insurance companies. They're going to raise the rates so high that it will make it almost impossible for any of us to get the care that we need. We will all be expendable as we have outlived our usefulness. Some darn bureaucrat with no medical experience is going to be responsible for determining what we need.

  • Ya to broken to work and pay taxes the king already has some one to wash his feet so into the pit with the lions jest kidding gwennie still praying that the bean counters will approve your surgery
  • I know I am lucky to have excellent health insurance. And when I have had to deal with W/C and no-fault car insurance I have been very lucky as well. I'm also not afraid to get on the phone and ask for help and info. I don't take no for an answer. Often getting the right answer is a matter of know what the right question is. Also I have found it is better to use honey with the person on the phone. Often they have limited authority but making them mad will not help. If they can't help you ask nicely for a supervisor.

    All that said. Gwen are you able to use the threat that prolonging the wait for surgery will cause additional damage? Often that is a huge weapon to use. Also are they paying you anything for being out of work? I know when my husband hurt his knee I had him approved and in surgery 3 days later because every day they waited cost more in W/C.

    Good Luck and try to remember the person on the phone is just doing their job.
  • Prior to 22 February, I would have said that I have always had excellent health insurance...top of the line coverage, best companies, etc. This denial totally caught me by surprise. They have paid everything else with not a single question, up until now.

    I understand the point you are making...but my surgeon has not had any more luck getting phone calls returned or finding out a reason why I did not meet their criteria. I am always polite when speaking to anyone on the phone. I'm just expressing my frustration here on the forum.

    Since you can't really predict how quickly nerve damage progresses, I don't think there is a way to predict what will happen in the near future. Actuaries don't care about the pain one is in, and how much it limits "life" as we previously knew it. I would have to develop cauda equina syndrome to meet their qualifications...and I'd just as soon skip that. Otherwise I need to develop a greater than 50% spondylolisthesis along with several more things to qualify for fusion.

    Employment does not enter into my equation.

    Had I known what I know today, I should have moved faster and scheduled my surgery in December 2009!!
  • I can't imagine having to have had to deal with all that prior to surgery. My heart goes out to you! I work for a radiation oncology office and I do the pre auth calls for the radiation treatment for cancer. We never even used to have to worry about getting auth for radiation, for God's sake it's cancer!! And now alot of companies require authorization. The Whole insurance world rules medicine. It's not right. Good luck on your approval. Lynette
  • Believe it or not bureaucrats have been responsible as long as I have been in the health care field, about 20 years. I remember getting a booklet of what was approved for what conditions:
    The original objective of diagnosis related group (DRG) was to develop a patient classification system that related types of patients treated to the resources they consumed. Since the introduction of DRGs in the early 1980’s, the healthcare industry has evolved and developed an increased demand for a patient classification system that can serve its original objective at a higher level of sophistication and precision. To meet those evolving needs, the objective of the DRG system had to expand in scope. Today, there are several different DRG systems that have been developed in the US.

    We said then the bean counters were dictating care. All these problems people are having now are prior to reform, and I don't understand while people don't think change is needed.
    The AMA, and the AARP, back reform. I think the accountants association might be against it.
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