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Lumbar Fusion surgery denied. Now What????

Does anyone have any suggestions, or maybe a good contact at Oxford?

O herniated L5-S1 two and a half years ago. I had a microdisectomy with partial laminectomy in June 2010. Herniated the disc again a week after the surgery. Revision surgery 4 months later. 4 months after that surgery a new MRI showed the disc herniated for the 3rd time. That was well over a year ago. I've been dealing with the pain ever since. Sciatica has gotten better over time, but low back pain keeps getting worse and worse.

I finally decide i can't take it anymore and schedule the lumbar fusion for June 25th. On June 8th my doctor's office called to say insurance denied the procedure. They have approved a laminectomy, but won't approve the fusion saying its not medically necessary.

My doctor got a run around trying to talk to their doctor for a peer to peer review. Doc for the insurance company based his entire decision on the radiology reports for my last CT scan and MRI. Wouldn't listen to anything my doc said.

I've had 3 opinions all saying fusion. My doc today went over my CT scan with me and said there is bone spur cutting right into the nerve. And the only way to get rid of it is to remove the facet joint to get in there and clean everything out. But doing that takes away stability and therefore, i need the fusion.

Insurance says i can have a laminectomy. Since when does insurance cover 3 laminectomies in a row? I thought standard practice was 2 decompression surgeries, then the fusion?

I can appeal, and i will do that, but right now, my surgery date is 5 days from now. I've got 2 kids at home, i have to time surgery around their schedule, and honestly, its best to be done while they are in camp all day. School hours are more difficult because they are shorter and the bus doesn't come to the house.

Does anyone have any suggestions to get Oxford to listen to me? The denial letter gave a phone number for my doctor to call, but i was told to call customer service. I hate to say it but customer service isn't going to be able to help.

I just don't know what to do. I have everything planned out, dates scheduled, and now this. Plus what if they continue to deny the surgery? Are they expecting to me to live with the pain forever? How can you fight the insurance company when you can't even talk to someone that can do more than look up my records in the computer system?

Sorry to ramble. i'm still stunned that we got nowhere with the peer review.
Microdisectomy / hemi-laminectomy 6/2010 and revision 10/2010
Cervical fusion C4-5 and C5-6 9/2011
Lumbar Fusion L5-S1 6/2012


  • I'd start by suing those no good bums. sounds like and insurance company only trying to save money. You have 3 doctors all saying you need fusion and they still refuse?? go after them in court. good luck
  • jlrfryejjlrfrye ohioPosts: 1,110
    edited 06/21/2012 - 10:12 PM
    State that the insurance company is causing you extreme pain by denying the surgery, Have you done all the usual procedures most insurance companies want done before surgery? Injection, physical therapy? In one of my surgeries it was denied because physical therapy had not been done even though my doc and I agreed it would do no good. So I went to one appointment and stated it caused too much pain. Surgery approved. Fight this just dont take no for a answer. Contact the insurance company and ask for a second level appeal. This will have to be done in writing and I believe the appeal has to be answered quickly at the second level. I would call and ask for a supervisor and a direct fax number to send the appeal. In your appeal state that the insurance company is causing you UN-necessary pain, denying a procedure that would correct a medical problem that will lead to future complications and most of all affecting your quality of life. Along with your appeal send the report of the 3 phy. who have recommended fusion. While you have the supervisor on the phone ask her if there is something in your medical records that is missing that would get this approved. Perhaps something is missing in their records that would automatically approve the procedure. If you do not have the records of the other docs opinions call their office and explain how urgent it is that you get copies of those records ( surgery is scheduled) I am sure they would allow you to pick them up immediately instead of the usual 30 day wait. Most denials are because of missing information. Good luck
  • after ALIF fusion last december i an tell you they are not all they are cracked up to be .first its a very invasive operation and in my case its failed and i am in more pain now that was before {and i had the uk's finest consultant }.count yourself lucky ! if you do have a fusion you mobility will be considerably reduced and there are many complications that you wont find out about until you have had it don't ..and by then it too late ..i thought that by now i would be feeling better sleep longer and be able to reduce mediation ..NOT the case i sleep Les take more meds and the pain is hell and i have even more medical problems now .the consultant said there is no more that can be done ,,,not what you want to here at 46.
    1997 laminectomy
    2007 repeat laminectomy and discectomy L4/L5
    2011 ALIF {L4/L5/S1}
    2012 ? bowel problems .still under investigation
    2014 bladder operation may 19th 2014
  • Well things have changed drasfically in a short period of time. Tuesday was just after meeting the surgeon to hear how he got nowhere with the medical doctors at Oxford. Wednesday night, with no change in status we wrote a nice long detailed complaint letter to the corporate big wigs. 3 from Oxford and 4 from united Healthcare. Well, that night one of the United people read the message. Thursday afternoon, i got a call around 12:30 saying my surgery is being approved. Oxford called me, then was calling my doc's office to get everything moving again. My doc was floored. Secretary was floored. We were in shock.,

    so from 12:30 thursday to now, i've had my pre-surgical testing done. And surgery is at 11:30 on monday. one more day to wait.

    Backache99 i do hear where you are coming from. Its one of the big reasons i've been putting this off for the last year. But i ended up with a 2 plus month flare with my back that started in March. It was hellish, and i don't want to keep living through those.

    I've got the herniated disc which is huge and pressing on nerves, but i've also got a monster sized bone spur pressing into the same area as the nerve. So those 2 things have to go. I just hope that it will mitigate the pain afterward. i'm not crazy enough to think i iwll be pain free, but i'd be happy with less pain and less frequent episodes.

    its amazing what a complaint letter can do. my doc is amazed that i got the approval, he figured we would be in for a nasty fight with the insurance. but talks about roler coaster ride. the ups and downs have been horrendous.
    Microdisectomy / hemi-laminectomy 6/2010 and revision 10/2010
    Cervical fusion C4-5 and C5-6 9/2011
    Lumbar Fusion L5-S1 6/2012
  • I totally understand where you are coming from. I've been questioning whether i want to do this surgery for well over a year now. In the meantime, i've also had a cervical fusion done. I'm just at the point, where i have to give it a chance. LIving the way i am now for the rest of my life isn't fair to me or to my kids. I just hope i come out better than worse. So far, i can say while i am not pain free from my cervical fusion, i am better than i had been. so if i can say that with the lumbar fusion, then i guess i can't complain.

    the one funny thing, as for the range of motion. i asked my doc how much range i would lose. His answer, " none." i looked at him like he was crazy, but he explained that i have so little disc left, its not moving anyway. So i really won't be any worse motion wise than i am now. At least if i can bed without sharp pains its got to be better, right?

    i'm sorry you had such a bad experience. have the docs been able to say why you have more pain now than before the surgery? what were they doing the ALIF for? mine is a badly herniated disc, and some huge bone spurs that are also pressing into the nerve.
    Microdisectomy / hemi-laminectomy 6/2010 and revision 10/2010
    Cervical fusion C4-5 and C5-6 9/2011
    Lumbar Fusion L5-S1 6/2012
  • time to get a lawyer if your doc got blown off by insurance. after 2 failed discectomies i'm surprised they aren't all over doing a fusion. maybe you waited too long and now gave em a free excuse.

    if you're almost bone on bone you lost ROM because it must hurt to move that section. L5/S1 is not going to limit your ROM. you can still stretch, touch your toes, whatever. don't let the surgery failures tell you not to get surgery. you have no idea what their history is and why they failed. just their moaning about it. my friend has L5/S1 fused. he complained for a few months and has been fine since. that's like years ago. it depends...
  • Congratulations on the great turn of events! Wonderful news for you, since you really want this surgery.
    Wishing you all the best tomorrow.Pretty soon you will be on the other side and on your way to recovery. May you have
    a smooth recovery and solid fusion.
    >:D< >:-D< : Karen
    L3-S1 herniation and bulges, stenosis, mod facet,ddd,impinged nerves,coccydinia
    discectomy/lami July 2011-unsuccessful
    adr L5-S1 Feb 2012
  • BlueSkiesBBlueSkies Posts: 59
    edited 06/25/2012 - 2:29 AM
    Hiring a lawyer and suing your insurance company is going to be a bit of an uphill battle because their defense is always, "you have the option of proceeding with the surgery on your own dime. We aren't denying you the right to have surgery. We are simply saying that the terms of your policy will not provide you any financial help." Additionally, you would likely be looking at a breach of contract suit against the insurance company (versus a malpractice type case which involves physical injury) and those cannot be contingency cases (at least in my state). This means you will have to pay the lawyer hourly for his work rather than a situation where he only takes a percentage of what you recover as his pay and if you lose, he doesn't take anything. Unfortunately, legal fees are well over $100 per hour, so you would be facing several thousand dollars in legal fees. It would almost be better juts to pay for the surgery yourself outside of your policy and see if the policy would at least cover aftercare. Well...almost. Doctors and lawyers, which cost the most...I can't say.

    There certainly are other avenues than the legal one, and it sounds like you not only found it, you were successful using it! So yea for you!! That is wonderful!

    I will be anxiously reading to see how today goes for you.
  • I just got home tonight. surgery was monday at 12. lots of pain, but thankfully the right collection of anti-nausea drugs and i was ok with that and the dizziness i usually get. Doc commented that once he was in there looking around, he knew for sure there was no way a laminectomy would have worked. the only thing to fix my problems was the fusion. So i guess its a good thing we got lucky with the complaint. At least i can say its over now, and i am home and can relax for a while.
    Microdisectomy / hemi-laminectomy 6/2010 and revision 10/2010
    Cervical fusion C4-5 and C5-6 9/2011
    Lumbar Fusion L5-S1 6/2012
  • SLC guy 23SSLC guy 23 Posts: 6
    edited 03/11/2015 - 3:44 AM
    I was recently denied. I did 3 months of PT once per week and 2 Epidural Shots for pain. I started with an older doctor who was 77. My condition was not getting better and he was moving towards surgery. I was able to get into a top ranked Orthopedic Dr. who also had a neurology background. He told me it was not if I needed the surgery just how soon. We filed and were denied. My doctor is someone with over 100 publications and is co-chair of a major universities Orthopedic Dept. Blue Cross of Blue Shield denied saying not medically necessary. The doctor tried to do a pier to pier review. They said it would have no impact on the outcome. We are appealing. The doctor even kept the surgery date open in hopes we would do the surgery. This doc has a 2 month waiting list of surgeries. It's still in the review process. They wanted 3 months of 2 times per week physical therapy with no improvement. I have instability in the spine.
  • I also wanted to add that my Doctor is so upset his scheduler says that he mentioned filing a complaint with the state insurance department. His assistant says that this is the first time in 15 years that he has been so upset.

    I've been in touch with a patient advocate for the company I work with. She seems sincere. Her comment was that the insurance company is trying to protect people from un necessary surgery. What a bunch of bull shit.
  • My last comment. If you are going down this road, before you file contact your insurance company and get their policy on the surgery you need. Make certain that all of the requirements are met. Unfortunately my insurance wanted ODI scores beginning and end below a certain level and 3 months of consecutive 2 times per week physical therapy with no improvement. A possible way around this is a letter from the physical therapist as to why you can not complete the therapy and why it is not in your interest. I am getting a letter from the PT today.
  • SLC guy 23SSLC guy 23 Posts: 6
    edited 03/22/2015 - 6:58 AM
    I am currently under an appeal. I've gotten the insurance company a letter from both the doctor and the physical therapist stating that I need lumbar fusion l4 l5. I keep pushing back. My understanding is that I have one more appeal and then a law suit.

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