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LOL, so my insurance sent me a letter denying my surgery

happyHBmomhhappyHBmom Posts: 2,070
edited 06/11/2012 - 8:48 AM in Health Insurance Issues
due to lack of "medical necessity." I guess they didn't see the pictures.

I assume this is standard protocol, but it's still funny.


  • MetalneckMetalneck Island of Misfit toysPosts: 1,364
    I feel the same way with SSD .... can't they see the picture??

    What is your insurance companies appeal process and have you started that ball rolling?

    So sorry they are play this cat and mouse game with you ... as if you don't have enough on your plate !!!

    Keep us posted!!

    Spine-health Moderator
    Welcome to Spine-Health  Please read the linked guidelines!!

  • I think they just needed some info my doctor's office forgot to send, so it will all be fine. It was just kind of hilarious.

  • HB,

    Like you needed more crap happening! Sorry, I sure hope this all gets fixed soon. Wow!!! I bet if it was one of their family members, they wouldn't appreciate such nonsense! Fingers crossed...

    PCTF C4 - T2, Laminectomies C5, C6 & C7. Severe Palsy left arm/hand.
  • Actually, they denied the insertion of the fixation device. Maybe they approved the removal of the vertebrae, but can't figure out why I need a fusion or anything once it's out?


  • Excellent ending reply HB to their "medical expertise" in so far as what you need! Rofla! Things like this make me really wonder anymore, what kind of training these people have? Argh!

    PCTF C4 - T2, Laminectomies C5, C6 & C7. Severe Palsy left arm/hand.
  • Wow... I think they get their "expertise" from a Magic 8 ball, lol. Does HB need surgery? **shake shake shake** Not likely!

    Hope it gets all sorted out quickly for you!!
    APROUD CANADIANveteranButNOTa doctor, my thoughts are my own
  • Wow, Sorry HB. At least you are half way there. My insurance denied both of my fusions the first time. I think in there office it is standard protocol to just deny and some people just except it and go away. Some times they enter the codes wrong on one end or the other but I am am sure they will figure it out. I would call them and call them and call them some more. They hate me in my insurance office :)


  • SpineAZSpineAZ WiscPosts: 1,084
    We had a member here who was denied fusion up the appeal chain at the insurance company until finally someone read the records and saw the MRI/CT/X-ray and suddenly there was approval.
    2 ACDFs, 2 PCDF, 3 LIFs; Rt TKR; Rt thumb fusion ; Lt thumb arthroplasty; Ehlers Danlos 
  • OMG! I just saw this post! HB, what can you do about this? I'm so sorry that you have to go through this! I don't know the health care system in the States so, I'm not sure of any idea's to help you with this. YOU need surgery!!! I'm hope this works out for you. I'm sure it must be frustrating to say the least!

    I'm here for you women! Verbectomy twins..

  • Well, I am approved for a fusion now. It's not what they originally tried to approve. I guess it was just a game of claim numbers.
  • HB,

    So glad to hear your insurance "approval" got squared away. So far I've been lucky with my insurance company and procedures/surgeries. :)

    PCTF C4 - T2, Laminectomies C5, C6 & C7. Severe Palsy left arm/hand.
  • So glad that you are approved. I had to fight my insurance co the first time all the way to the state level. They denied the fusion the day before surgery and so I had to fight and get it 4 months later.
    This time, I started the process way early. It is the same senario as last time, so maybe since we have all our ducks in a row, so to speak, it will help the process. I am nearvously keeping my fingers and toes crossed!
  • What do you mean to the state level? My son was scheduled for surgery last Monday and they sent a letter of denial on Friday, as not medically needed. The Dr did a Peer to Peer and it was denied, he also did a 72 expedited appeal and that was denied, he then did an expedited internal board review and that was denied, and now it is going out for an external review, we have no idea how to get prepared for that. Now we find out his company is self funded and just uses BCBS for filing and handling it's claims, so how do you go to the state with it? I don't understand that at all. His Dr. states he can't even renew his slip to continue being off of work as he isn't going to be able to schedule his surgery but he can't drive the hour and a half to and from work so theirs no way he can go to work unless he can get the surgery. I can't believe it but I don't think it will pass the external review either. What then and how do you bring it to the state, when his company is self funded they actually don't have to comply with state laws they have to follow federal regulations only?
  • SpineAZSpineAZ WiscPosts: 1,084
    Employee benefit plans can be either fully insured, or self-funded. (Self-funded plans may also be called self-insured). Under a fully-insured employee benefit plan, the employer purchases health coverage from an insurance company, and the insurance company assumes the risk for payment of claims. The insurance company is regulated under state law and is subject to rules about mandated benefits, network adequacy, prompt payment of claims, etc. Other employers create “self-funded” health plans for their employees. In these self-funded plans, the employer keeps the risk to pay the bills and usually hires a plan administrator (insurance company or third party administrator-TPA) to process the claims. When an employer self-funds the plan, it is generally not subject to state laws and regulations -- so state mandated benefits, state prompt payment rules or standards of network adequacy don’t apply. Sometimes insurance companies act as an administrator to process claims for an employer self-funded plan. In these circumstances and wearing the plan administrator “hat”, the health plan is not subject to state laws and regulations.

    Often in this case the employer can help make the decision and "push" for the insurance company to approve a request for services. This works well if the employee has a good HR/Benefits department and can then ask for a meeting or special review.

    What is the reason they are giving for denial? If there is a review it's critical for you (or someone close to the situation) to write an objective letter stating "here are the exact reasons this procedure is needed and why it's the only option".

    Below is a link that may be helpful. There was some recent talk about mandating self funded plans be as accountable to the state as fully insured plans. The Department of Labor (in the link below) may be able to provide guidance on this


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