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Newbie Here Fusion Needed Anthem BCBS denying HELP!

GammyDebGGammyDeb Posts: 3
edited 06/11/2012 - 8:52 AM in New Member Introductions
Hi everyone,

My name is Debbie. I'm 49 years old, a wife, mother & grand-mother. I've lived with back problems all my life. I was in a horrible accident 44 years ago. I lost my mom in this accident, almost lost my dad & first injured my back. I'm going to try to keep this short....In 1987 I fell in my house & ruptured 2 discs. I had a laminectomy at L3/4 & L4/5 by an orthopedic doctor. I was in the hospital for 3 weeks with a blood clot and other problems. But, I did recover from this surgery. I was able to go back to work when my youngest started school. While working in Dec. of 1997 I re-injured my back and had to have another laminectomy same levels. I recovered amazingly fast from that. Then in 1999 someone hit us and re-injured my back again. It took 2 years and me losing my job by the time I found another doctor to do surgery on my back. In 2001 I had my 3rd laminectomy at the same levels with bone spurs removed. This surgery and the one in 1998 were done by a neurosurgeons. I was doing good with flare-ups from time to time. Many doctors would dance around the idea of doing a fusion but then never would. In 2008 a neurosurgeon told me to have gastric by-pass. I did this & lost 110 pounds & life seemed to be doing great. I tried to go back to school & had to have an rehabilitation evaluation & I failed this. Not only did I fail this, it set in motion severe pain & weakness in my leg again. That was Jan. 2010. In Nov. 2010 my youngest daughter got married and all the running around trigger a bad flare-up. I got into pain management & was able to enjoy the wedding. But, after the wedding I had a few more sessions done to get me stronger. Well, my right leg started giving out & I started falling. My pain management doctor has been great but he decided to do another MRI (this time lumbar, thorasic & cervical) I started having problems with my bowels & bladder. So with the results and the new problems, he sent me to a neurosurgeon. Neurosurgeon says I NEED A FUSION ASAP. Well, Anthem BCBS has denied me. He did a peer-to-peer last Thursday & I was denied again. I have started the process for a grievance appeal. I seriously can not take this pain anymore not to mention the fear of what is being permantly damaged.

I need advice please, how do I go about getting this approved? I did some research into the guidelines that they are using. It's the Milliman Guidelines 14th edition. It seems I need 3 to 6 months PT to even be considered. My doctor said to do this, but stressed to me that I really need this surgery ASAP! One thing I noticed was if he were to do a bilateral fusion, they would cover (if I'm understanding it correctly) & I am having bilateral problems & even had pain management on both sides. Should I show this to the doctor? Will the insurance kick everything out if we try to do it this way? Advice please! What's an expedited claim? I saw someone mention that on another thread.


PS He was going to do a TLIF L3/4 & L4/5 & my pain management was concerned about him not doing L2/3 also. I have a few bulging disc in my thorasic & L 2 is not right either. Also, possible future surgery of L5-S1 anterior fusion. I WANT A NEW BACK!!!!

PSS In 2003 & 2008 I was in 2 other accidents that totaled my vechiles...none of these were my fault or the person driving the vechile I was in---1 out right ran a red light & hit us twice & the other was a hit & run 1 week after my gastric by-pass (I was on my way to the doctor for follow-up)

If some of you know Ulyssia, I'm her mom...she is the one that recommended this site to me.


  • About possibly Diagnosing you with Cauda Equina Syndrome and doing this as a Emergency.

    The Bowel and Bladder problems would support the Diagnosis. If after surgery he does not feel that you have cauda equina syndrome, he can put it in the Post Op notes.

    Im very surprised you have not had a Fusion done yet.

    Also doing that Extra Disc down at L2 is not always a good idea when you are already doing 2 levels. It complicates things.
  • I went to my surgeon's office today to drop off the information I found online about the Milliman's Guidelines. He & his receptionist weren't in today. I left the information with the other receptionist & showed her what I had found. She asked me if I would have ever thought I would have to work so hard to get help, but sounded hopeful that doing the bilateral decompression would qualify me. I will ask him about your suggestion when I get to see him again. I had to go to my regular md today to follow up an ER visit & for more meds. She was shocked also by what this insurance is doing to me. She said I have saddle block anesthesia syndrome. She isn't the first one to tell me this.

    Thanks for the advice on L2. It would make sense the more they do the more chances for problems & not holding up. With this next surgery being my 4th, I wanted to make sure that they did everything they could and hopefully not have to have another one.

    Have a blessed day!
  • hi and welcome to the forum! :H we are here to offer you support and answer what questions we can. good luck with getting your pain issues resolved.. please be sure and stay in contact with a doctor!! stop by the forum anytime!! Jenny
  • Thanks for the welcome Jenny. My daughter, Ulyssia, loves this forum. It means alot to have others going through the same thing I am that can offer support and advice. I hope to be able to help others one day. No one deserves to live in pain!
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