I’ve been seeing a chiropractor for almost 6 years now due to pain and lack of feeling in my right thigh and significant lower back pain. I started seeing her after my back “went out”, and over the course of a few months she managed to get me to a point where the pain was livable (my pelvis was continually moving out of line to compensate for the pain down my leg, and when she added up the total number of degrees I was out at various places when I first saw her it totaled 90, so it was significant!)
About a year and a half ago I was having to increase my visits to the chiropractor, and eventually a year ago I went for an MRI which basically showed varying stages of DDD at all levels, some bulging of some discs and severe degenerative facet disease at L3-4. Saw an orthopedic surgeon who also did x-rays which showed a bone spur at L3-4. He suggested an ESI to see if it would help resolve the pain, however, it didn’t help at all, in fact it made the pain worse for about 4 -5 days. Then had a nerve conduction test and EMG which showed severe radiculopathy in my right leg. Yeah! - proof that the pain and numbness I’ve been having for over 5 years is real! Went back to the Dr and he suggested facet joint injections - so tried that. No benefit from them, but at least they didn’t cause too much more pain like the ESI had.
Dr then said as everything we’d tried had been unsuccessful the only option was to go in and do a laminectomy to remove the bone spur at L3-4 which would stop the leg radiculopathy (no guarantee that full feeling would come back to the leg, but at least the pain would go) and hopefully the issues I was having with my pelvis continually going out of line would be resolved as that compensation by my lower back would no longer be an issue. Said he’d need to do a fusion of L3-4 as it would become more unstable due to removing additional bone to get at the spur, and given how poor L4-5 looks he’d request to do a double fusion now rather than having to back in a few years to do L4-5. Dr did say, when he heard that I had Blue Cross insurance, that they would most likely deny surgery on the first request and that then he’d get to go to bat for me a do a peer to peer review.
Dr was right - BC did deny (“ ...There is no evidence of an unstable spine that would benefit from a spine fusion operation.” ). So he called and did a peer to peer, and was basically told I hadn’t tried all conservative methods and needed to do physical therapy before they would consider surgery. Dr commented that physical therapy isn’t known to help issues with bone spurs, but I had no choice, so went to 12 sessions of physical therapy at my own cost as it wasn’t covered by my policy! Physical therapy didn’t help - even the physical therapist said he doubted it would, but at least he said the exercises were the same as those you do after surgery so I was getting a jumpstart on strengthening those muscles!
Dr resubmitted request for surgery. Second denial came back (“...Your provider has documented that you have aging or degenerative disc in your back at multiple levels, L2-3, L3-4, L4-5, L5-S1. The request to fuse L3-4, L4-5 two levels will not resolve your back pain. You will not meet the Milliman criteria for two level fusion with a multi level disc disease. You will not qualify for an exception because you have 4 level disc disease”).
Dr was furious and requested another call with BC. Basically told appeal/grievance needed to be in writing, and so he submitted all my history to them. Final decision came back, (on day 30 of their 30 days, of course!) with a final denial (“medically unnecessary....your MRI do not show that you have any narrowing at any level of your back where your dr is planning to do surgery.....”) and the comment that this now exhausted my grievance rights with them and the only other recourse I had was to request an independent medical review from the California Department of Insurance.
I’d love to hear from anyone who’s had success getting a denial overturned this way, and would welcome any other suggestions or ideas on how I might be successful. Has anyone used a lawyer to help in a situation like this?
I have lived with increasing pain and a noticeable and ever decreasing quality of life (I used to be highly active, now even taking the dog for a walk is hard) for over 5 years, and having come to terms with needing surgery in order to improve my quality of life I am beyond frustrated to come up against this ludicrous bureaucratic entity called Blue Cross which does not seem to have a patient’s best interests at heart.
Thanks in advance for any help