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3rd denail for fusion by Blue Cross - any suggestions?

calijanccalijan Posts: 1
edited 06/11/2012 - 8:59 AM in Health Insurance Issues
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



  • I had the understanding that many insurance wanted a series of 3 epidural injections that failed before a fusion could be considered when you have disc disease. I realize that epidurals don't help instability.

    I also understand that MRIs typically show softer tissue issues while CT scans help show issues with bones. MRIs do not show a lot of disc issues. A discogram is considered by many neurosurgeons to be the gold standard of tests to show disc issues such as annular tears(that sometimes an MRI will not pick up.) An EMG does not show instability.

    I'm not a spine dr., but what you present doesn't seem clear to me. Of course I believe you that you have pain and that something is wrong, but I don't understand what has been done to prove where and what your disease is. You obviously have a problem but I don't understand what it is from those tests. The tests show facet disease and a bone spur at one level, then some bulging of some discs. If you have disc disease at adjacent levels before fusion, it's going to get worse. Is BC trying to say that you need more than 2 levels fused because you have 4 level disc disease?

    My point is that maybe different tests that are more insurance company standards might improve approval chances. Also, get a different surgeon to see you and possibly order those tests. The tests and documentation you have don't seem to me to justify what the surgeon wants to do. If another surgeon examines you, orders discogram or whatever he feels necessary, then submits for approval for surgery, would that help?

    Sorry, never appealed an insurance claim more than one time. I really feel like you don't have the full picture of what's wrong in your back at least from an insurance perspective.

    Good luck, please update on what happens and I hope you get some relief soon!
  • Many insurance carriers are now using those Milliman criteria and, according to my surgeon, in 22 years of practice he might have had 5 patients who would meet the guidelines...in other words, they are very specific...and keep a lot of patients from qualifying for surgery. One of the main criteria for fusion is an instability.

    Another acceptable reason for fusion is radiculopathy, but it must be clearly visible on imaging, or you need to be able to prove it somehow. I found that my insurance carrier would NOT accept the results of EMG and nerve conduction study as proof.

    They are not keen on OKing multi-level fusions and seldom give approval for DDD.

    These and similar criteria have had their "desired" effect. If you talk to any spine surgeon, you will find out that their practices have changed quite a bit in the last couple years. Far fewer fusions are being done now.

    I don't know if there is much variation among states' insurance boards. I would imagine that you could find the guidelines for a review online on your state's insurance regulation board's website. I'm sorry I cannot say if you'll have any luck in that regard. In this case, I don't really feel hiring an attorney would do much good. If your doctor was not able to persuade them that your medical problems met the criteria, a lawyer won't have much to work with.

    I suspect if you read your policy carefully you will see that it covers surgery that is deemed "medically necessary." These are two little words that basically take the power to make decisions away from the surgeons and gives it to some insurance company employee with no medical background, or in the case of appeals, perhaps a small amount of medical knowledge.

    I imagine you could get the OK to have the smaller surgery on the bone spur. Then if you did develop instability, you'd "qualify" to have the fusion.

    Sorry to sound so negative...but this is how it works with the insurance carriers that use the Milliman guidelines.
  • I suggest that you get 2-3 more surgical opinions and have them submitted (NS/OS). They will usually pay for these.

    I would also call them and keep track of everything thing they tell you. One thing that helped me was asking for a copy of my surgical request and everything in my file (all claims leading to it). Once I started going through it I found several issues like- they only sent part of my history to review for approval & they lied and said they were using a NS to review and it was a medical examiner.

    Both of my fusions were intitially denied by my primary insurance however my secondary (bcbs) had immediately approved. I know how frusterating it can be.

    I was in a MVA April 2010.... I basically have 4 different insurance companies and none of them have paid any spine related bills since the big day. Prior to that I didn't have to pay out of pockets since I have double health coverage. I owe about $37,000 and haven't had any major treatment yet....

    Hang in there.
  • I had ins on my first two spine surgeries but I used this on my shoulder surgery in Nov and it was about $20,000 total. I do have two more spine surgeries and I will have Hillburton to cover those as well.


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