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Help with appeal process

SplendagrrlSSplendagrrl Posts: 108
edited 06/11/2012 - 8:56 AM in Health Insurance Issues
I had surgery scheduled for Oct 17 and my insurance just denied my two level lower lumbar spinal fusion. The reason was because my DDD did not show spine instability. It's weird nothing about disk buldges, my pinched nerve, or bilateral radiculpathy in both legs. My pain is severe and I have electric nerve shocks down both legs and my right leg buckles all the time. My doctor is in the appeal process. So now I am waiting on news about what is going to happen. I would like any advice about how to appeal or any information from anyone who has been through this. I have many surgeries that I have had and they have never been denied. I do not remember if I can mention insurance here but I have Anthem Blue Cross. It is usually a very good insurance. This has me so upset I feel I am at square one. I think the insurance might want me to have a decompression first. I don't know. Thanks


  • jlrfryejjlrfrye ohioPosts: 1,110
    Ive never heard of a insurance denying a surgery for no instability. Did you have nerve testing done? Compressed nerves is enough evidence for the surgery. Allow your doctor to handle the first phase of the appeal. Perhaps they just needed more medical documentation. If you are still denied feel free to PM me and Ill walk you thru the appeal process. This is what I do for a living, billing medical claims and fighting with insurance companies on a daily basis. Im sure your doc will get this approved if the medical documentation is there
  • dilaurodilauro ConnecticutPosts: 9,868
    One - Let your doctor handle this one initially. They have a lot more medical input and should be able to provide all the justifications required.

    Two - I've never heard about Insurance denying surgery due to Spinal instability.

    As long as your doctor agrees with the surgical procedure that they want to take, they should be able to put together whatever is necessary to get the approvals from the insurance company.

    Has your surgeon offered other alternatives? Just really curious to understand why they havent been able to convince the insurance company to go ahead and approve your surgery.
    Ron DiLauro Spine-Health System Administrator
    I am not a medical professional. I comment on personal experiences
    You can email me at: rdilauro@veritashealth.com
  • Hi Susan,

    Thank you so much for your offer of help it was sooooooo appreciated!, Good news is my surgeon spoke with insurance and it was overturned immediately and approved! Yeahhhhhh! So now I do not have to even go through the appeal process, my surgery was deemed medically necessary! They had just not read all the facts! Thanks again!
  • Thanks for responding. At first the insurance said the surgery was not medically necessary and they denied the fusion. Apparently they had not read all the doctors notes. So my patient coordinator had to cancel my surgery date, then she told me they would appeal and it could take 3 to 6 months! Then I read about my insurance online and they are denying lots of fusions. Some people are appealing up to three tomes and for years and they still deny. Anyway I was totally depressed after finding out all of that. Then what happened is mu surgeon had a peer review with the insurance spine specialist and they overturned the ruling and approved the surgery deeming it medically necessary. Thank God! So suddenly I am set for surgery in a little over two weeks on Oct. 17th. :)
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