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Insurance denied my surgery! :-(

Txlady57TTxlady57 Posts: 8
edited 06/11/2012 - 8:57 AM in Health Insurance Issues
Good morning spine buddies,

My fusion for L2,3 and L3,4 was scheduled for Dec. 13th. I was estactic thinking I MIGHT have a chance for this horrible pain to be alleviated long term. Everything was set...or so I thought. I am a retired Texas teacher and taught for 30 yrs. I would still be teaching if it weren't for my back. I have A.... insurance (didn't know if I could put the name) which I pay $300 a month for....the doctor's office called and said my insurance said the surgery was too experimental. They said even though my tests show I have no disks left at all and my vertebrae are inflamed and damaged...that only a fracture, cancer, or dislocation would be covered for a surgery.

I called the insurance company crying and talked to three different people...the last one being head of the nurses. She said the doctor and I could appeal; yet, the appeal would go straight back to the same doctor that decides my fate. They had talked to my doctor that morning. My doctor had done my first four fusions which have NO pain whatsoever...a success.

I don't know what to do now. My hydrocodone does nothing for my pain. The doctor in Dallas was going to put me in a back brace after the surgery. Do any of you have one? I do not have a back doctor in the small town in which I live now....but they can refer me to one in a town 100 miles away. I have tried Lyrica and Cymbalta and muscle relaxers to no avail. When bone is grinding against bone I don't know what will help. The insurance company told me to not bend!!!!! That is a joke. Try not bending getting into a car, using the toilet, etc. I am mad, sick with disappointment, and sad. Any advice?????

Hugs from Texas,


  • SavageSavage United StatesPosts: 5,476
    ..beside yourself!
    I wonder if doc wrote up the order for your surgery in an odd way..that insur co read as "experimental".

    Maybe doc can rewrite order in more accepting way.. i dunno.

    I don't really know, but maybe getting most recent notes from you doc and re petitioning you insurance co.for able to have your surgery....maybe that would help approe surgery.

    Maybe a second doc opinion???

    Let us know how it works out for you!!

    Spine-Health Moderator
    Please read my medical history at: Medical History

  • jlrfryejjlrfrye ohioPosts: 1,110
    Have you tried all the usual methods before surgery will be scheduled? Physical therapy and injections? What is the doctor doing that the insurance company is saying experimental? Is he talking about using a artificial disc? There is something in his wording to the insurance company that is causing a determination of experimental. Collect all your medical records and appeal your claim with all records attached. If you need help with the appeal process Ill be more then happy to walk you thru it. Go to your insurance company web site and there should be a form for appealing. Ask for a expedited appeal due to the pain and suffering you are enduring due to the insurance company denial. Good luck
  • I appreciate your comments. The doctor and I both are going to file an appeal. My doctor is a well respected doctor in the Dallas Fort Worth area that was named as one of the top doctors in Texas. He actually talked to the doctor at my insurance company. He is not asking to use an artificial disc....a fusion to attach to my other rods. My insurance company states on their site that ANY LUMBAR surgery is denied UNLESS it is cancer, a fracture, or severe scoliosis. They deem it experimental on ANY lumbar surgery due to percentages they use.

    The appeals will go straight back to the doctor at Aetna that denied it in the first place. My doctor was so upset that they denied it that he called to talk to this doctor. Many of you have asked me if I have been to pain management, physical therapy, etc. Yes, I have been thru it all except for wearing a back brace. I have been on Hydrocodone since my first surgery in 2005 which the surgical area never hurts at all. What hurts is no disk left at L3/4 and the other lumbar disks show moderate damage. My spinal surgeon said a spinal shot would only last a hour. I don't know what to do....I am sitting here on two ice packs. I take two to three 10 mg. Hydrocodone pills a day and live on ice packs. They have given me oral steroids, but they did not help. They say they don't like to give too many steroids in a year, as a side effect is heart damage.

    So...right now...I am left to just wonder why and try to keep my spirits up. I have cried buckets, but all it does is give me a headache. lol I think the Obama healthcare situation is hitting everywhere. These insurance companies certainly take our money each month, but do not want to help us when we NEED it. By the way, I had to pay out of pocket for my MRI and my Cat Scan due to dedictibles and major medical. The insurance year started in Sept.....grrrr..

    Hugs and thanks again,
  • SpineAZSpineAZ WiscPosts: 1,084
    Do you have an HMO or a PPO policy? HMO's are far more restrictive. And many insurance companies are pushing back on approving spine surgery BUT if your doc is one of the best he and his insurance staff can try to navigate around that.

    Do you have a Pain Management doctor? You mention hydrocodone but don't mention any long acting medications like Oxycontin ER, Kadian, Opana ER, MS Contin ER, etc.
    2 ACDFs, 2 PCDF, 3 LIFs; Rt TKR; Rt thumb fusion ; Lt thumb arthroplasty; Ehlers Danlos 
  • seriously i would be rather hesitant having had 4 fusions and then go have another surgery, but that's just me. the research literature tends to point out that the more surgeries one has the more we open ourselves up to risks that are just not worth taking. i think much better pain control would be great for you. i also have had multiple surgeries and my doctor has said i am not a good candidate for more surgery (which i don't need now anyway). but even if i was in need i still might not be a good candidate. it has taken a while to get reasonable pain control. i have a lot of limitation and have had to give up many things, but since i am not rocking in a fetal position in the corner writhing in pain i am happy. my pain by no means is gone but i am able to function reasonably. i am only taking enough medication to keep me someonewhat cognizant. basically i have pain but only medicate it to the point where i can both function reasonable and cope with learning to live with chronic pain.
  • Put simply, my spine is a mess and I have had eight surgeries. While they have stablized the spine, the pain has does nothing but increase. I have two new ruptured discs and will not have anymore surgery. I am in a wheelchair now as I no longer safe even on a weight baring rollator. Medicaid will no longer authorized outpatient PT as they say it is no longer helpful. Medicare actually told me that I am not a good investment anymore. Good luck.
  • SavageSavage United StatesPosts: 5,476
    ...a very rough way to be told you are no longer covered. That therapy no longer beneficial.

    Is sometimes difficult to not have that absorbed into who we are as people. I hope you have strong support system who remind you regularly of your worth and who help you as you continue to navigate the system to get your pain relief.

    Glad to see you share that info on this site and hope this site able to be support to you, also. I am glad you wrote about what Medicare said to you.
    Those people need some help with people skills.

    Hope this weekend is refreshing and pain tolerable for you. Take care!
    Spine-Health Moderator
    Please read my medical history at: Medical History

  • MarkkalkMMarkkalk Posts: 1
    edited 07/18/2012 - 1:56 AM
    Discuss about Medical Insurance. How many Important of life.

  • TXLAdy,

    As people have said appeal it. It sounds to me like there is a disconnect between what you think you are having for surgery and the code the dr is giving to the insurance co.

    Call the Dr, and find out what they are reporting to the the insurance co. It could be a case where the Dr is reporting some new procedure that has not been around long. I have never heard a fusion is new, so keep digging, and I think it is a coding mistake. Good luck.
    Left foramina stenosis of L3/L4 (retrolisthesis)
    L2-ilaic revision fusion ( loose screws) with a laminectomy at L3 (cage at L3-L4)
    (PLIF) -@ L4/ L/5 - S1 (cage at L4/L5)
  • Hi,

    I noticed you had surgery not to long ago. How are you?

    I long to hear from others that their fusion was a success.

    My name is Jayni and am trying to go in for a revised fusion to the L4L5 L5S1.

    My first fusion was back in Nov 30, 2010. Due to continued back pain and sudden increased pain I finally had an MRI done in March 2012 followed by a mylogram where they say my back did not fuse in the L4 L5.

    I was scheduled for June 7, and now my doctor and insurance informed me I was not approved. The insurance company does not think I need this.

    That makes me mad. We pay so much money out and the benefits get worse every year.

    My doctor will be appealing but I just wonder if I should continue having suregeries.

    Would I actually fuse on my own if I just don't have this done?

    The ct scan showed loose hardware where it was not fusing and he said something about the infuse he wanted to use and now I just want to hear from those who did have additional screws added and did okay.

    11/30/2010- 360 bi level fusion L4 L5, L5 S1
    7/5/12-Revised surgery. Remv of loose hwdware, replace 6 pedicle screws and 5.5 titanium rods. Inferior laminotomy R L5 and facetectomy to deep ligamentum.
    2014 MRI indicates L3-L4 disc bulge,
  • you are welcome to use mine. i didnt need one on the revised surgery.
    Its a medium. Send me your info and i can send it to you.

    I am still waiting on my Bone Stimulator. I have one from my fusion in 2010 but they won't reset this. Still waiting for the insurance to approve.

    This is ridiculous. I will be praying for you!

    Hugs from Denton Texas
    11/30/2010- 360 bi level fusion L4 L5, L5 S1
    7/5/12-Revised surgery. Remv of loose hwdware, replace 6 pedicle screws and 5.5 titanium rods. Inferior laminotomy R L5 and facetectomy to deep ligamentum.
    2014 MRI indicates L3-L4 disc bulge,
  • Kml0690KKml0690 Posts: 2
    edited 02/03/2013 - 4:38 PM
    I also had my surgery denied. I went through all the pretesting and was all ready and they denied me two days before. I appealed twice and I was still denied. I was told there is nothing else I can do. I have degenerative disc disease plus two herniated discs and I have tried everything. They keep telling me it is not medically necessary. The only thing that seems to help is percoset without Tylenol but I don't want to be stuck taking this forever I have been up crying constantly and as you all it does is give me a headache. I don't know what else to do. My heart goes you. I was going to do an external appeal with the state of New York but the insurance company told me I can't because I do not work for the state. This is not right that they can deny you a chance for relief after paying them all this money.
  • kris123kkris123 MassachusettsPosts: 1
    Kml0690: so what happened?  My 22 year old daughter is in the same place.  Surgery denied 2 days before the planned surgery.  We have Aetna in the Boston area.
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