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Angry enough to spit bullets and nine inch nails

I was scheduled, still am, for a fusion revsion on 6/9. Films (CT/Nuclear scan) show two loose screws in S1, pseudoarthrosis of S1-L5, partial collapse of L5 and a partial compression fracture on the right side of L5. Symptoms show continued compromise of nerve at S1 along with urinary retention and lumbar radiculapothy.

This morning the insurance company, kaiser, called me this morning and said it was denied, despite a neurosurgeon doc to doc because their doc can't see the pseudoarthrosis. they said I needed to have the CT and nuclear scan reread by a third party. They offered me a second doc to doc with a different kaiser neuor within 48 hours.

Now here it is on a Friday, my neuro is in surgery all day. I called his office and his assistant said she had just gotten the denial fax before I called. She was furious because according to my neuro he needed to have the thrid party radiologist's report and send it as an addendum and we would be all set. The denial was never mentioned to them, just that approval would not be given without the report.

Both the insurance rep and my doc's assisatnt assured me that there was plenty of time to get this settled before next week. I'm going to carry on making home and work preparations as if everything is going as scheduled. The only people who know, that it will effect, are my husband and my boss. The plan is to be ready for the 29'th and if not then, as soon as it is approved.

Thanks for letting me vent, I'm just so angry right now.


  • I know it can be very frustrating. Its good that you are able to vent on here. Good Luck, I hope everything works out for you.
  • Thank you..two things have happened since I posted. The radiologist who had originally read the CT scan has sent an addendum to the insurance company. and, please see new post in the surgery section, while waiting for approval yesterday (July 3) I ruptured my disc at L4-L3.
  • I just had my fusion done on 6/25. i didn't get approval from the insurance company until the 21st. doc kept talking to their peer to peer doc people, and they just wouldn't listen to anything he had to say. Everyone figured it was a lost cause. well, my husband and i drafted up a nice complaint letter, and managed to get it to 7 of the high up executives with oxford and united healthcare (since they're owned by the same company.) one of them read it wednesday night, and thursday afternoon i had my approval. But by then i had missed the pre-surigical testing date, and had one day left before the scheduled surgery date to get it done. thankfully the doc's office was able to get everything rescheduled for that day. but i totally understand, your doc says you need it. and the insurance company doesn't listen to them, or to your reports. (mine said they only look at the report from the MRI's etc, they do not look at the actual images. and of course in my case, the bone spur they didn't see on the CT scan is what would have made them change their mind.) and they had no interest in looking at the images and told my doc that.

    good luck with the insurance company. i hope you get somewhere soon.
    Microdisectomy / hemi-laminectomy 6/2010 and revision 10/2010
    Cervical fusion C4-5 and C5-6 9/2011
    Lumbar Fusion L5-S1 6/2012
  • My doc said the same thing about them only looking at reports and not films. Finally last Friday the radioligst sent them an adendum to his report that included halos around the hardware and the pseudoarthrosis. meantime with the additional disc rupture i now listed as emergency surgery.
  • tran92ttran92 Posts: 183
    edited 07/04/2012 - 9:04 AM
    i hope you get it approved as emergency surgery and can get this fixed. the insurance companies will be the death of their patients for lack of care. i could go on and on about that with my own case. but i am sure you understand. what kills me is they won't let us talk to their doctors, they won't let us see their doctors, and they won't listen to our doctors. they thin kthey know everything but don't listen to anything.
    Microdisectomy / hemi-laminectomy 6/2010 and revision 10/2010
    Cervical fusion C4-5 and C5-6 9/2011
    Lumbar Fusion L5-S1 6/2012
  • Thanks for listening. My doc offered me the choice of being admitted to the hospital yesterday to wait for the surgery or to go home on pain meds and wait for his call. He's almost positive that I won't have the sugery till Friday but says he may admit me tomorrow through the ER and for me to call him in the morning.
    Hope you are healing well.
  • Not sure what's going on with the insurance end of things but the hospital just called me to say I am scheduled for surgery tomorrow
  • sounds like someone got it approved. otherwise i doubt the hospital would have called. they'll want their money in the end.

    good luck with the surgery. i hope it helps this time.
    Microdisectomy / hemi-laminectomy 6/2010 and revision 10/2010
    Cervical fusion C4-5 and C5-6 9/2011
    Lumbar Fusion L5-S1 6/2012
  • Just heard from doc's office..insurance has approved it
  • Just thought I'd add a few things here.

    1. I got home from the hospital Last night and today got a letter from kaiser telling me that they approved me after reconsideration.

    2. My doc told me that they never called him for a second doc to doc after receiving the addendum, just called his office and said it was approved.

    3. In pre-op the handed me the consent to sign and I saw that the off label use for the bone modifying protein had been hand written in. I insisted that the doc either show me where they ahd approved it or find an alternative as I cannot afford to pay out of pocket for it. He was able to, delayed things for a few moments though.

    4. While I was in the hospital the insurance company called me on my cell phone to ask if I needed to schedule a f/u appointment for my visit last week to the ER.

    and finally today
    5. I received a letter from the insurance company telling me to call them and discuss why I went to the ER (where my neurosurgeon was since he operates on tuesdays and is only ten minutes from where I was when my disk ruptured and where he told me to go and he would meet me there all the while right foot was getting weaker and putting weight on my left heel caused horrible pain in my lower left back) instead of going a 45 minute drive to their nearest urgent care center which woulod have none of my neurosurgical records since I refuse to let their docs touch my spine for any reason.

    (they botched a simple finger joint fusion last year requiring a second surgery and six weeks on nasty ABT for osteomylitis)
  • glad you're home. i hope you're feeling better.

    its amazing what the insurance companies do. nothing make and sense with them. mine after finally approving the surgery (which came from corporate, not the doctors) let me get through the surgery. then as i'm being discharged, the nurse is telling me how i am getting visiting nurse services along with PT at home. (this is the 4th back surgery, and second fusion, never had any of that stuff in the past) so i'm confused, but not going to complain. for 3 visits of each, and then somehow got approved for 4 more nurse visits (and only saw PT once because technically i'm not supposed to be doing PT this soon after a fusion.) but on top of that, oxford's nurse line is calling me weekly to check up on me and see how i am feeling and if i need anything.

    All this sudden concern when they consider my surgery "not medically necessary." i still don't understand it all. but at least its not over, and i can move forward instead of sitting and worrying and fighting.
    Microdisectomy / hemi-laminectomy 6/2010 and revision 10/2010
    Cervical fusion C4-5 and C5-6 9/2011
    Lumbar Fusion L5-S1 6/2012
  • My doc offered me the option of being revealed to the hospital yesterday to wait for the surgery treatment therapy or to go house on suffering medication and wait for his get in touch with. He's almost good that I won't have the sugery until Sunday but says he may acknowledge me the next day through the ER and for me to get in touch with him in the day.
    Hope you are therapy well.
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