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