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Ins denied spinal fusion~trying to gather info for appeal

Hi, I'm new here~I am a 35 yr old female with L2,3 S1 herniated discs. I have been dealing with this for 5 yrs, in Aug along with siatica, I started having pain & weakness in my left leg, making it very diffuclt to walk, sit, and live a normal quality life. I have tried conservative treatments, none of them worked.
My neurosurgeon proposed surgery, a spinal fusion. we scheduled the sugery & had all pre-op testing done. Find out week before my surgery, the insurance company did not approve the surgery. The NS had a peer to peer with the insurance companies MD, but it was still denied. There reason for denying is because per clinical policy there is no evidence of spondylolisthesis. However there is evidence of spondylolysis and stenosis.

So my question is, is spondylolisthesis common with L2,3 S1 disc herniation, or is it limited to L4,5? Does there need to be evidence of this condition for a spinal fusion to be performed. I am going to be appealing this with the insurance, so I am trying to gather information that maybe helpful in my appeal;
any information is appreciated. :)


  • Did your doctor explain why the fusion was required over a microdiskectomy and decompression for the stenosis?

    It sounds like that's where your insurance company is going with this, that they only approve fusions if there is documented instability. Personally, I am not a fan of insurance companies practicing medicine, but they all do :(

    Did your doctor even mention the possibility of a less significant procedure? Did you get a second opinion? Did your insurance discuss what they'd approve?
  • I second happy's post. Standard treatment for spondylolisthesis is fusion due to it causing instability. Good luck and keep us posted...

  • I don't really know if my doctor explained why the fusion is required over a microdiskectomy or decompression for the stenosis, at least it was not explained to me.
    I'm now making a list of questions for my doctor and the ins co. I will be calling my ins co tomorrow to see if there is another proc they will cover instead of the fusion.
    Thank you so much, I really appreciate it :)
  • Well, maybe it is a good thing that the insurance did this, because at least now you will know what your options are and make sure that the fusion (the most drastic surgery) is required over the surgeries that require less recovery time :)

    Definitely consider asking your insurance company for a second opinion so that you can see if another doctor has something different to say about your condition. Also read the Spine Health article on questions to ask your surgeon!


    One of the more important questions I learned to ask was "why." Why the fusion? Why there? Why using that method? A good surgeon will be happy to answer those questions.
  • Sometimes the insurance companies are a good thing. Doctors have their own preferences which might not be in your best interest. ANd you always have to keep in mind that this is how they earn their living and they have bills to pay. Always ask why and what else...
  • The doctor said that I have L2,3 discs are severely damaged, the fluid in the spongy material between the discs is dried up; the discs are bone on bone. I also have degenerative disc disease, and from the inflamation and the herniated discs, I have a pinched nerve that effects my lt leg with pain & weakness. I beleive this is why a fusion was proposed; due to the damaged discs. My sugery was supposed to be a spinal fusion and laminectomy.
  • I have been "penciled in" for c2-c5 fusion and decompression for April 20th. Kaiser referred me to an outside NS about 6 months ago and he suggested the fusion and told me to get a second opinion from the Kaiser NS which I did (it took them three months to get me in to see him). The Kaiser surgeon said he would "see to it that it would get approved" but now I am not convinced that he has the power to do that. My surgeon's scheduler (the outside network one) said that Kaiser wants to talk to my surgeon to discuss the treatment plan. This supposedly will happen Monday.

    I am now in a great state of anxiety. My problem does not seem as serious as many I have seen on these boards who have been denied. Yes I am in pain all the time. Like I have an icepick in my neck. I have bone on bone at my facet c2-c3 and degeneration on down to c-7. But if I am fairly sedentary I can manage quite well. I seriously need to distract myself.
  • I, too, am in terrible pain with spondylolisthesis and 2 dry herniations at L4 and L5. I have been misdiagnosed for 4 years, and after finally being correctly diagnosed, 2 different surgeons (one ortho and one ns) recommended surgery and Humana Access has outright denied the first request, with the 2nd stating PENDED.

    So, I just wondered if you ever got approved and if you have any hints for me to make it happen.

    Thx, Jan
    Janis Haertling
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