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5 weeks from surgery - Insurance Question

subvet1969ssubvet1969 Posts: 34
edited 06/11/2012 - 7:56 AM in Health Insurance Issues
If anyone could answer I would appreciate it very much. Looking at my spine issues noted in my signature, does anyone see any problem with me getting approval from my insurance company for this surgery?
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Comments

  • SpineAZSpineAZ WiscPosts: 1,084
    Every insurance company is different in how they evaluate a claim and/or request for coverage. Your surgeon's office likely has staff dedicated to insurance that has already submitted a request for coverage and may have received a provisional approval (approval that states it will be covered if it meets all the insurance company's guidelines and limits for the surgery. After the surgery the doctor's office submits surgical report to talk about what was found and how it was fixed).

    There are so many different possibly provisions in a health insurance policy AND every insurance company has coverage guidelines they look at when a request for specific surgery is submitted.

    I would guess that if you are already scheduled for surgery your surgeon's office has done what is needed to secure a request for coverage. They'd be the ones to tell you where you stand. Many surgeon's office won't even schedule until they have provisional approval.
    2 ACDFs, 2 PCDF, 3 LIFs; Rt TKR; Rt thumb fusion ; Lt thumb arthroplasty; Ehlers Danlos 
  • Thanks for your comment SpineAZ. I would think that there would have been some sort of pre-approval before they scheduled my surgery. They never mentioned that they did one. I let the doctors office know of my concerns for approval of this and they said they usually don't put in the claim request until about 2 weeks prior. Does that still mean they may have put in a provisional request earlier? It makes no sense because I am scheduled for my pre-op testing and back brace fitting right before that 2 week point (about 3 weeks from now). Wouldn't it be silly to get the pre-op testing and back brace and then be denied surgery? I'm not really sure how this works and maybe I'm worrying needlessly. I have pretty decent insurance...Anthem BCBS of Ohio and its a large group policy that I'm on through my employer. I've read a lot of horror stories on SH and its worrying me to no end. I just want to get this done and get better so that I can get on with my "new life."The neurosurgeon said the likely thing that will fix my problems is the laminectomy/discectomy surgery which will require a 2 level fusion afterwards because the removal of the lamina etc will cause more instability. Thats the reason for the fusion amongst stopping movement of the painful segments. I'm not sure what the other surgical options would be if they did deny the fusion. It seems like a lot of others on SH have been mentioning insurance companies are getting bad about acting like your doctor instead of relying on your doctors advice. Maybe insurance companys should be combined with a doctors office since this is how they want to play. Thanks for your input and hopefully I'll get some more input from some other SH members.
  • When it comes to insurance, you never know! That being said, usually, a week to 10 days, they'll want you to be cleared from your GP. Blood test's, EKG,chest X-rays and anything the doctor thinks needs to be done to know if you're in shape for surgery. I'm suppost to have an ALIf Oct,17. I live 4 hrs. from where I'm having my surgery. I've got an appointment Oct. 13, to be fitted for a brace & go over the surgery with the surgeon, then to the hospital. When they told me the date of surgery, they added, that they wouldn't start the ins. stuff until Oct.7. I won't know anything until then. I really don't know why they haven't started. Until I hear from them, I'm not assuming anything. Insurance companies are getting really fussy about about lumbar fusions. Good luck, Brenda
  • Thanks for your comment Brenda. I've heard they are getting fussy about fusions also.
    My PLIF is scheduled for 11/4/11 and my pre-op testing and back brace fitting is on 10/21/11. I just hope everything is approved and smooth sailing.

    I wonder if insurance companies show prejudice when it comes to approving or denying patients' procedures based on what group they are in? For example, If I'm on a small group policy, would I be more likely to be declined than if I were on a large group policy w/ 5000 employees. I can imagine if it comes down to money, it probably is a deciding factor, although they wouldn't dare tell the patient that. What is covered for one patient, may be declined for the next, even if they have the same identical problems.
    My insurance has always come around for me, so hopefully they will in this instance also, even though the cost will be considerably higher than any other thing we've been covered for.
    Good luck w/ your surgery and keep us posted on your approval status and recuperation.
  • I'm with Anthem BCBS Mo. It'll be interesting to see. Good luck to you as well. Take care, Brenda
  • SpineAZSpineAZ WiscPosts: 1,084
    If you are getting pre-fitted for a brace ask the orthotic company if they have submitted for approval of the brace. If they have, and it's been approved, then you know at least that is covered.

    Your surgeon's office's insurance staff knows what Anthem BCBS needs for approval, so they likely wouldn't schedule surgery and brace fitting etc if they felt there would be a fight to get it covered.

    While fusions are being questioned by insurance companies it is more often when there is no testing to show a reason to fuse. There were times when any long lasting back pain led to fusion. From your information it appears you've had extensive testing and evaluation which led to the surgical decision.
    2 ACDFs, 2 PCDF, 3 LIFs; Rt TKR; Rt thumb fusion ; Lt thumb arthroplasty; Ehlers Danlos 
  • Thanks SpineAZ....you mentioned some good points there and gave me some hope. My neurosurgeon is a respected Dr and has done lots of fusions and the such, so I'm sure he does know what the "tricks of the trade" are.
  • SpineAZSpineAZ WiscPosts: 1,084
    It's actually his staff that knows the most. Surgeons know very little about insurance and depend heavily on their administrative staff. The surgeon will know in general which insurance carriers are more open to certain procedures, but once the option of a procedure is brought up the surgeon's staff jumps through hoops. It often takes months after for all bills to be settled, but that's not something that affects you. It took 9 mo for my surgeon to be fully paid, it's just a bargaining game of insurance asking for information, it being sent from the doctors, back and forth and back and forth.
    2 ACDFs, 2 PCDF, 3 LIFs; Rt TKR; Rt thumb fusion ; Lt thumb arthroplasty; Ehlers Danlos 
  • Well, my L4-S1 fusion along with a laminectomy & decompression was denied. Had to cancel my pre-op testing that was scheduled for today. My surgery was scheduled for next Friday (a week from today). The reason for the denial was that my surgeon supposedly did not mention that there would be 3mm or greater of vertebral slippage. Let me say, the reason for requesting the fusion was because of the instability that the decompression and laminectomy would cause. My surgeon put that in some other words but the insurance surgeon obviously didn't accept my surgeons choice of words when he explained the slippage/instability in other terms.Since my surgery is in 6 days and I still need to get my preop testing done and back brace fitting, my surgeon scheduled a peer to peer for this Mon or Tue to ' better explain or clarify why the fusion is necessary. It sounds like a clarification is all that's needed, so I'm guessing the denial will be reversed and immediately approved during the peer to peer. I'm hoping the p2p review works out because I can't take the shooting pain and numness much longer. Its going to be a long busy week next week if it is approved...approval on Monday or Tuesday, pre-op testing & back brace fitting on Tue or Wed, and then surgery Fri morning. Has anyone else heard of this or had the same stressful issues? Its quite depressing being at a point of now not knowing if my much needed procedure is going to be approved...especially being so close to the surgery date and getting everything approved and done in time. I've got 6 days till surgery, but I have faith in my surgeon and his awesome office staff...I'm sure they will 'Git'r done.
  • Hi, how are you? I hope you're able to get through the weekend without too much stress over the ins. issues!!! It seems like no matter what I do, something stops my ALIF!!! It appears, I've been focusing too much on my back, and not taking care of the rest of my health. When your spine scream's all the time, it 's difficult to think about the importance of the rest of my body and it's need's! I thought I was healthy except for my spine issues... And I might be, I might just need a tune-up!!! Lol
    I'm waiting on my test's! I've lost alot of weight( 20+lbs). I've done this in a very short time. I thought the weight loss was due to the stress and pain of my spine. I have a history of stress and how I handle it. In other words, loss of control in what is going on in my life, ='s my control over eating! Not very healthy thinking! We'll see if what I've been doing has caused my health to decline! Now, I can't have a fusion, until I'm healthy enough for it! I'm hoping, it's a simple fix! Vitiamins, better diet, and so on & on! And nothing more serious! Good luck with the peer to peer, and all your pre-op test's, I hope everything goes well, & you get your fusion!! It sounds like you will. Take care, Brenda C.




  • Just found out that my initial denial for a PLIF has been overturned with a peer 2 peer. I'm finally all set for my surgery this Friday. I have been mentally drained the past few days worrying about it, but prayer got me through it!
  • Great that you are now approved. I know how hard it is to deal with insurance companies.

    Hang in there,

    Julie
  • Thank you. Yes they can be difficult, especially the more serious it is. It has stressed me out like I've never been stressed in my life. I have wanted to get this done for so long, I'm tired of feeling like crap.
  • Hi Brenda,

    Did you get approved by your insurance and have you had your surgery yet? I was just checking in with you to see if you had any insurance issues. I was initially denied for my L4-S1 but a peer to peer got it reversed. My surgery is Friday 10/21/11 (2 days). Reply when you can and hope everything went ok with surgery if you had it.

    Best,

    Bryan
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