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I've joined the denial club :(

texastigerttexastiger Posts: 48
edited 06/11/2012 - 8:44 AM in Back Surgery and Neck Surgery
I received my DENIAL letter via certified mail last week. Surgery is still scheduled for June 11th--XLIF and PLIF of at least 3 levels with hardware removal at L4-S1.

My NS called the insurance company for a peer review and they told him that he should have called the day before and it was DENIED. He asked what to do and they said to start the appeal. The appeal process was immediately started but they said to my NS "don't call us, we'll call you." That was 1 week ago.

The insurance company told my nurse NOT to tell me what was going on and that I would NOT get a DENIAL letter. She called me right away. I received the letter the next day.

I have called my insurance broker and he has made phone calls, but that is the extent of what I have done, besides pray. The June 11th date is very important to me because my husband is a high school teacher and coach and we have 4 children. I feel like I can't sit back and wait for the day to come and go. I am not one to fight hard!

For those of you who have gone through this, I need any and all advice-Please!!




  • Here is a question? If you not one to fight back then who is. This is your life. If you want any thing does you got to fight back as hard as you can.

  • My advice...you take control of the process and let your doctors and insurance companies do the work.

    1 - call the insurance company and find out steps to appeal. If you aren't clear or they are 'loose' in their instructions, you ask again. You ask to speak to their manager or someone in appeals to help.

    2 - you talk to your doctor's office. Typically there is someone at the office that is great at helping navigate the insurance companies. Figure out who that is...a nurse or admin. Talk to them, ask to set up an appointment to go in and 'see' them to have them walk you through their experience with this and with this for your specific insurance company

    3 - start pulling together all your records -> Office visit notes, images, radiology reports, opinions from 2nd/3rd doctors and outline the history that's led you to this "need" for surgery. Prepare the story....the opening, the middle and the 'argument' that there is NO other option.

    4- keep coming on here and perhaps others can help you in how to approach it. At minimum, you will get folks like me "cheerleading" for you to stay persistent.

    Don't get discouraged if you can't get surgery on the date outlined but use it as a driver to stay on top of folks
  • DNice and Jim for the encouragement! I just found out that my NS had a peer review on Friday with the Ins doctor. I am waiting the results of that meeting this week. In the meantime, I am putting my steps into motion.

    Thanks so much,

  • I really hope that this all gets sorted out quickly and that you can still go ahead with your surgery on June 11th.

    It must be awful emotionally. X(

    I would definately try to gather all your documents and records in case you need them.
    Meanwhile pray!!
  • sorry cant give advice, just wanted to wish you good luck with your insurance issues. these insurance sometimes act like robots and have no feelings.
    hope everything works out for you.
    My Best and keep fighting them.
  • How long have you know about the denial?

  • May 14 my nurse called me to let me know what was going on. On May 17, I received the letter from the insurance. The appeal process started on the 14th.

    My NS feels very positive about the peer review and we should know this week.

    Thanks for all the encouragement.

  • it all works out. If you really want to go through with this, then fight you must. I'm sure you know that this surgery is not for the faint of heart, having been through a fusion before. Please be aware that the road to recovery from a three (at least) level fusion is a long, hard, twisty one. I'm a year and a half out and finally am feeling like I have my life back. I'm stiff, but I'm fairly pain free. Playing ball with the dog helps get me flexible.

    3 level spinal fusion, L3/4, L4/5, L5/S1, November 2008. Stiff, but I can walk.
  • SpineAZSpineAZ WiscPosts: 1,084
    Let us know how it goes. Unfortunately what we're seeing is more denials these days.
    2 ACDFs, 2 PCDF, 3 LIFs; Rt TKR; Rt thumb fusion ; Lt thumb arthroplasty; Ehlers Danlos 
  • Hi Becca! I had 3 different surgery dates while we waited for insurance to process the paperwork.

    It became a matter of "she said/he said" with both sides saying info had been sent and they had a paper trail.

    My surgeon became very angry and personally got involved! From that point, it was approved in less that 24 hours!

    I am a firm believer that everything happens for a reason! The day of my surgery (360 L4-5 fusion) I was the only surgery of the day! :) So, my surgeon did the entire surgery without distractions!

    I know this is a stressful time and having all this on top of it just adds to the stress!

    Try to just procede and prepare to the best of your abilities. Getting your reachers, raised toilet seat, satin sheets (I got mine from overstocked .com), setting up the area you will recover in~recliner or bed room!

    We are here for you and I wish the very best for you! I know what it feels like!
  • Hi there...I was just thinking after reading the other's responses, that you are in a good place if your doctor is talking to the review board.

    The key to the appeal is understanding why they denied you in the first place. The cool thing (looking for positive in this) is that your doctor should be able to get this for you so that he can help you figure out the best way to approach the appeal to confront their reason vs. just appealing having no idea why it was appealed or how they went through the initial process.

    Keep us posted.
  • I just got word that my surgery has been approved. My NS talked with the insurance in a peer review and the insurance has now approved the surgery.

    The surgery is set for June 11th. I have to go back to the NS on June 3 because new motor issues have developed and they may need a more current MRI and myelogram before the surgery since the tests are 9 and 7 months old. I am hoping that this doesn't push the surgery back.

    Anyway, thanks to all for the wonderful encouragement. It was quite an emotional time dealing with the denial. Now, the surgery has its own issues.

    Blessings to all,
  • Becca,

    So glad to hear this is resolved, and darn, in a pretty fast time frame! I think it is great that your NS stepped up to the insurance folks and all is well. Good luck with your upcoming surgery!!! *HUG*

    PCTF C4 - T2, Laminectomies C5, C6 & C7. Severe Palsy left arm/hand.
  • It's wonderful to have the possibility of recovery out there in front of you, isn't it? I can tell you recovery will be long and rough, but hopefully, you will be glad you did it within a year and a half to two years. Hang in there!

    3 level spinal fusion, L3/4, L4/5, L5/S1, November 2008. Stiff, but I can walk.

  • Now you can just prepare yourself mentally for the surgery! :jawdrop:

    My MRI scan that the surgeon used was 9 months old and he did find that things were a lot worse than he had expected. So if they do want to do more tests or scans, it will help them to prepare for what needs doing.

    Have you got any plans to have fun over the next week or so? Spoil yourself a little :)
  • Glad to hear you got approved.
    I'm also glad to hear they are sending you for more tests. It's always key to making sure they are as prepared as possible for what to find when they operate.

    Best wishes and post up in June surgeries b/c I'm trying to check that thread to offer my support to all June surgeries folks!

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