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I am scheduled for a fusion in two weeks and CIGNA is denying coverage..

Anyone else run into their Insurance Company denying coverage? I understand Insurance Companies are really cracking down on fusions, but I was just interested if anyone else ran into this problem and how it was resolved. I will appeal it, because I can't live with this pain, but just curious if anyone else had this problem?
I'm SO frustrated!


  • Cigna also denied coverage for me a couple weeks before my surgery. I called Cigna and the doctor's office. Sometimes the doctor's office may not send enough info.is what I was told. The lady I spoke with at Cigna was very nice and helpful. Anyway the doctor's office called Cigna and they approved the surgery. Hope this helps. Good luck with your surgery
  • dilaurodilauro ConnecticutPosts: 9,858
    company name. We do not allow naming of specific establishments.

    But, when I read your post and then saw the follow on, it just reminds me on how strict the Medical Insurance coverage is today.. Insurance companies are cracking down on procedures. All that is really necessary today, is for the doctor to provide the insurance company with all the correct words and diagnosis.

    I know people on both sides of this... Insurance companies do not look at the 'people' aspect when reviewing cases. Its really up to the doctors to provide enough information so that the insurance company can do nothing but approve the procedure.
    Ron DiLauro Spine-Health System Administrator
    I am not a medical professional. I comment on personal experiences
    You can email me at: rdilauro@veritashealth.com
  • i got denied for my last fusion too. insurance claimed it wasn't medically necessary. told the doc to speak to a specific person to do a peer to peer review. doc from insurance wouldn't get on the phone with him, he spoke to 3 other docs, none of whom would even do anything even if they agreed with my doc. insurance went soley on an MRI report saying i had a herniated disc. they would approve a laminectomy, but not the fusion. meanwhile, if they had seen the CT scan images, they'd have seen the half inch long bone spur i had pressing into a nerve root. we went through hell trying to get them to approve, but they kept saying no.

    we finally complained in writing to several corporate executives. one of them read the letter on a wednesday night, by 12:30 the next day i got the call from insurance saying they are approving my surgery. funny thing, they called me 1st, then my doc. i sent an email to my doc and he almost didn't believe me, he was convinced we'd have a 6 month long fight in appeals to get approved. (this all happened 5 days before my scheduled surgery, where i had already missed the pre-surgical testing date, and they had cancelled my time slot) thankfully they didn't give it away yet and we got it reinstated. but what a nightmare.

    and insurance still says it wasn't medically necessary. (oh and my doc showed the images from my CT scan to a room full of 200 doctors, and every one of them agreed i needed a fusion, not a laminectomy.) go figure.
    Microdisectomy / hemi-laminectomy 6/2010 and revision 10/2010
    Cervical fusion C4-5 and C5-6 9/2011
    Lumbar Fusion L5-S1 6/2012
  • tlcgtr01ttlcgtr01 Posts: 3
    edited 11/07/2012 - 9:20 AM
    First, my apologizes for not knowing that we weren't supposed to name specific establishments. :-)
    And thank you for the information given.
    My surgeon had to cancel my surgery scheduled for Nov. 15th and move it to Dec. 3rd, in hopes that he can convince my insurnace company that the surgery IS needed. It's so frustrated living with the pain. I was told 3 years ago I needed a fusion, but decided to just have the diskectomy, because it wasn't as invasive. Now I am in constant pain, and feel that my life is being put on hold. I have two young girls and used to be very active. I've gained 20lbs in a year, due to not being able to work out at the gym, and it's really just getting depressing at this point. I have an appt. today with my surgeon, to see what the next step will be. I will fight until I get what I need/want, but I just can't imagine living with this pain for another month or two while I convince my insurance company I need the surgery.
    I guess I don't understand that with 3 Orthopedic Dr's recommendations, X-rays, MRI, tons of epidrual shots, TENS unit ($100 out of MY pocket), Medial Block, Radiofrequency Abalation, and PT, the insurance company doesn't understand I need it. :-(
  • I just had this happen to me.
    1st, the insurance company wanted the doctor to tell them why "inpatient" was medically necessary. (really? this isn't minimally invasive surgery!)
    Once the doctor responded, they received another fax notice that my claim was denied because I need to be free of smoking for 6 weeks prior to surgery.
    WHAT? I have a cardiologist and pulmonologist clearance already in place, which was already provided to the insurance company.
    I have had 2 previous spinal (minimally invasive) surgeries and my insurance company at the time NEVER made up their own restrictions.
    I don't know if this is discrimination or not, but I'll be 62 this month, I got laid off from my job last July and kept my insurance through COBRA because the coverage was good. And I have been a smoker for over 50 years. I think they just want rid of me. I pay a very high price through COBRA to keep my insurance and now this? 6 days before surgery! I can't pay for this on my own. My deductible has been satisfied and I think they are ready to cut me off. Without this surgery, my spine will collapse. I have an implant from surgery #2 that failed and the screws ripped out of the spine and the devise is just laying inside my back. Fusion is the only hope. I can't even walk through a grocery store for 5 minutes without a riding cart. The spinal nerves are being compromised and I am losing feeling in my legs and have electric shocks down both legs. Really makes it impossible to look for a job.
  • LC84LLC84 Posts: 599
    edited 04/04/2014 - 7:54 AM
    Is it possible to have further communication between your Dr's and insurance company?? Maybe reschedule the surgery for 6 weeks from now and try to quit smoking in the meantime? I know kicking the habit can be very difficult. Around here many Surgeons won't perform the surgery if you're a smoker because it disrupts bone growth. I'm sorry you're going through this, especially so close to your surgery date. The other option would be to go forward with the surgery, then apply to get some of the costs written off if your current income qualifies you for something like that. I wish you luck and hope that you can find a way to have the surgery.
    Progressive DDD
    Chronic S1 Radiculopathy
    Discectomy L5-S1 2002
    Discectomy, Laminotomy/Foraminotomy L3-S1 January 2014
    Bilateral SI Joint Fusion and 2 level spinal Fusion October 2014
  • Your chances of fusing properly while smoking are not good at all. They do have a medically valid reason for declining the claim because of that risk and the surgery failing as a result. I know my surgeon will not operate on anyone who smokes.
    10/28/13 - ALIF, PSF, decompression at L4/L5 and L5/S1
  • The original post is from 2012.
    L5/S1 TLIF July 18, 2013
    4 Screws 2 Rods and BMP
    Post surgery L4 Dermatones
  • i have a ppo and i am not sure if you insurance is HMO or PPO. mine does not require any conditions and i can go to any doctor and have anything done that my doctor feels is needed. i have never been denied for any fusions or any other procedures. of course teaching does have its perks, like insurance that i do not have to pay for. i do have a $200 deductible at the beginning of the year and only a $5 co pay for office visits. unfortunately, my pain meds are covered but i have to pay $375 for a month's supply of oxy and fenatyl lollipops. i can have an HMO if i wanted to but i am no fan of them. i don't need permission or denial of any meds, basically i can go and have anyting done that my doctor and i feel is necessary. of course in august when i retire i go to medicare but my district has paid for this also. i have monies taken out every month to pay for it so when i retire, i basically don't have to pay except for a co pay. my wife has the same that i do but she has to pay some out of pocket for hers and if i wanted to be on hers after i retire, it would be a little too expensive so that is why i will be on medicare. i feel sorry for some of you that have to jump through hoops to get things done.
    I have 4 fusions from L5-3, the latest last May '12 where they fixed my disc that broke.They went through my side this time. I take 40 mg of oxycontin 4x a day and 4 fenatyl lollipops 300 micro gms 4x a day.
  • If they are denying the surgery stating you need to quit smoking, then you do have options, appeal the decision, have your doctor give you a prescription for wellbutrin or chantix to help you stop smoking, or quit on your own. The issue is that the tar and nicotine interfere with the fusion process and can really reduce the chances of a successful outcome of your surgery.
    Even if they use bone morphogenic protein to supplement the start of the fusion process, there are no guarantees with you still smoking.......
  • cjack311ccjack311 Denver, COPosts: 1
    I am supposed to have a multi-level fusion on 8/30/16 but just received a letter yesterday from my insurance company denying coverage.

    They are citing the need for better documentation of low ODI scores (showing signs of little improvement since treatment started). I've been in intense core stabilization physical training and therapy for more than 6 years now. Additionally, they are requiring "documentation of a preoperative psychiatric/psychological evaluation conducted by a licensed psychiatrist, psychologist or other licensed mental health professional who has a working knowledge of the psychological issues involved in chronic pain syndromes." So they think I'm imagining this?? Why would anyone voluntarily go through such a surgery and the extensive recovery if it was anything but a last resort to resolve severe, debilitating pain? My latest MRI reflects two fractured vertebrae, spondylolysis, bone spurs and two completely dissolved discs.

    I recognize that most insurance companies will deny surgeries just because they don't want to have to pay for them (hard to turn as big of a profit when you actually have to cover something). I won't mention the name of the company here, but based on some of these other posts - it is their standard M.O.

    Is it not enough to go through the pain itself and the psychological trauma of knowing what one faces with surgery itself and then recovery, but then we have to fight tooth and nail just to get them to follow through on what we PAY THEM FOR? I'm really struggling with this - clearly. Thanks for letting me vent. I appreciate this forum - as sometimes being in constant pain can make one feel all alone on an island. It helps knowing there are others out there who understand. I'm sorry you go through it as well!
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