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Insurance requiring dangerous test for surg auth.. L4-S1 fusion

chowhoundcchowhound Posts: 3
edited 06/11/2012 - 8:52 AM in Health Insurance Issues
Hey all, I am new but have lurked around for some time.... very helpful site, thank you all!
I am hoping someone might be able to shed some light on my situation. I am 46, love to excercise and Ive had two successful spine procedures:
2006, C5-C6 Anterior Cerv Fusion at EDITEDUniversity Med Center. All symptoms relieved.
2009, L4-L5 decompressed at EDITED Med Center. Huge relief of abdomen pain.
April 6 2011 I was scheduled for L4-S1 fusion at EDITED my "most excellent" doc. 30hrs pre surgery insurance cancels authorization due to third party review assessing "not medically necessary". "Peer to peer" review revealed the physician who reviewed my case is NOT a spine specialist, does not have a practice, is retired and living in Florida. The report demands the following tests be done for authorization:
PT - (51 PT appts done from 5-17-07 through 1-19-2010 at EDITED in Fresno, 2 PT appts at EDITED Medical Center then returned to CA)
CT myelography w/contrast - (MRI with contrast done 1-4-11, positive nerve root compression L4-S1)
EMG - (2-18-11, 3-11-11.. nerve root injections at UCSF, confirmed w/limited positive response L4-S1 right side(1 1/2wks), left side(36hrs)
BLOOD WORK - (done 3-28-11)
PSYCH EVAL - (??????)
HOME EXCERCISE - (I swam 2000yds the day before C5-C6 fusion at EDITED Med Center... I walked 3-5 miles per day post cerv surg)

Dr EDITED, due to ethical compliance cannot order unecessary, dangerous tests. But Allegience can?

Numbness from nerve compression at L4-L5, L5-S1 is
creeping from my feet through calves to hamstrings. Sept 2010 symtoms no longer relieved by bed rest, traction still works. Feb 2011 traction working less. Today, feet and calves are staying numb, traction no longer works. And I continue to decline.

Any insight would be greatly appreciated.
Sincerely, Doug

Post edited to remove names of medical professional and facilities by Moderator haglandc


  • SpineAZSpineAZ WiscPosts: 1,084
    The doctor should work with you to appeal this and show that some recommended treatments or test are not needed or are contraindicated. They do require that there is proof of medical need and if something is clear on CT/MRI the doctor can question why a CT myelogram is recommended. CT myelogram can be useful if MRI is not quite clear or a better picture of what is going on is needed.

    It sounds as if much of this is the problem of the insurance company IF they had a peer review and it was NOT a spine surgeon. Your doctor can appeal the medical part and you can question why a spine specialist wasn't considered an option to review all available tests. And lay out for them all the tests and examinations you've had done. If you had a second opinion who also agreed you need surgery, then get those records also to show 2 surgeons agree on the need for surgery.
    2 ACDFs, 2 PCDF, 3 LIFs; Rt TKR; Rt thumb fusion ; Lt thumb arthroplasty; Ehlers Danlos 
  • Thank you for the reply SpineAZ. My surgeon is helping with my appeal. Since the peer to peer he has written a letter to the insurance co explaining the evidence/tests that supports his position. The insurance co just yesterday agreed to a second review. Regarding the myelogram, myolopathy was ruled out with the MRI w/contrast, also I do not and never have exhibited any symptoms of myelopathy.

    Thank you for the suggestions. In progress. So far I have contacted all docs to get all my records in one place. The ins co payed for 51 PT appt's which they did not forward to the reviewing physician. I went ahead and did the psych eval, all is ok there. But, I learned from the doc who saw me that he had never done, nor ever heard of any of his colleagues doing a psych eval for orthopedic surgery, bariatric surgery sure, but not spine surgery. Only 4 bills to learn this. I will be requesting a referal to another spine doc fri from my primary for a 2nd opinion.

    My wife and I are trying to get an "in person" spine doc review from the insurance co. It simply does not make sense for a physician on the other side of the country to presume he can assess and make conclusions about a patient without seeing the patient in person. Meanwhile blatantly disregarding those experts who have seen the patient.

    Thanks again for the info/suggestions.

    BTW, my apologies to all for including names, it will not happen again.
  • SpineAZSpineAZ WiscPosts: 1,084
    Good idea for an in-person examination. Would you be willing to absorb your co-pay for that exam? Given that your insurance may not be administered down the street or even in the same state, maybe the insruance company has a database of consulting physicians in your area that have offices for an exam. Not sure, but maybe they agree but ask you to pay your portion. In my case a specialist co-pay is $40, so it's easy for me to say yes if I was in the same situation as $40 isn't a lot. But other people have less generous insurance.

    Are you out of work and receiving any STD/LTD for the disability? If so, and your employer is large, they may have an interest in getting you surgery that can get you back to work if possible. Many large employers are self-insured meaning claim dollars paid out are employer monies. Years ago my hubby, in his mid-40's, needed a tonsillectomy. The insurance company denied it, but his boss didn't know (owner of the company) so he saw my hubby at work the "day of surgery" and asked why he was there, hubby told him surgery had been denied and thus canceled. Hubby went to a meeting and by the time he got out there was a message on his phone from the surgeon's office saying "Not sure what you did but we just got a verified approval". Hubby's boss went to the insurance broker and said "I need this guy healthy for business and they cancel a necessary surgery? If I look at his throat I can see those gigantic tonsils...want a picture...better yet I'll bring him over to your office." That was enough for the broker to call and say "The employer is the fiduciary and as it's their money they request that this be approved. Now this is somewhat unique but not out of the question if the insurance is through your employer or that of your wife, HR/Benefits can be approached and asked "Does our company have any influence on medical claims, I'm in a quandary as my surgery/my husband's surgery was canceled less than 2 days before it was to happen as it was denied by insurance. What can you do if anything?"
    2 ACDFs, 2 PCDF, 3 LIFs; Rt TKR; Rt thumb fusion ; Lt thumb arthroplasty; Ehlers Danlos 
  • The insurance issue was resolved two weeks ago, I would have written sooner but my wife and I have been moving to another city. At any rate, after insurance denied surgery authorization deeming the procedure not medically necessary, my wife and I embarked on a letter writing campaign to the insurance company and human resources at wifes employer. We conveyed my surgeons and primary care physicians refusal to order the tests the insurance companies reviewing physician stated as necessary, emphasizing the facts that a retired doc 3000 miles away is in no way capable of diagnosing a patients condition while ignoring nearly ten years of patient history, and is in no position ethicly to order tests for conditions the patient/me has never exhibited symptoms for and that create unnecessary risks to the patient/me. Not to mention that my physicians had already eliminated or identified the possible issues at hand. It turns out the administrator of the hospital my wife works for contacted my wife regarding the insurance coverage expressing dismay and anger that the health ins was treating his employees like expensive car accidents... a certain cost threshold crossed, immediate denial based on canned opinions presented by out of state non practicing physicians. Insurance companies fishing for folks who will just roll over and give up. Oh well, major emotional hassle especially when my condition continues to deteriorate, but there is light at the end of the tunnel. Thanks so much for the insights and idea's!!!!
  • SpineAZSpineAZ WiscPosts: 1,084
    Do you foresee approval coming? Is your wife still working there and insured?
    2 ACDFs, 2 PCDF, 3 LIFs; Rt TKR; Rt thumb fusion ; Lt thumb arthroplasty; Ehlers Danlos 
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