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Lumbar Laminectomy/Fusion and Tlif

I am new to the forum. I was scheduled to have a Lumbar Laminectomy w/Fusion and a TLIF of the L4 and L5 on May 9th, 2013, due herniated discs, bone fragments and Spondylothesis Grade 1. I have a Medicare Advantage PPO health insurance plan which covers In- Network and Out of Network providers Obviously I would have a.higher OOP for the Out of Network. I chose to go with my doctor (spine specialist) who was Out of Network because he did my 3rd Cervical Fusion (posterior) in this past December, 2012 for cervical stenosis. I previously had cervical fusions in 1999 and 2005. As I was scheduled for my PCP clearance exam and Hospital Pre-testing, my Insurance informed my doctors office that they would cover the Laminectomy and Fusion, but not the TLIF. They denied the TLIF as "not medically necessary", under the Investigational/Experimental clause.

My lower back problems have been going on since December of 2010 and I have tried all the conservative forms of treatment including steroid treatments, physically therapy, epidural injections and pain medications. I actually had first seen the spine specialist doctor for the lumbar problem and was headed toward surgery when the cervical stenosis took hold and that was more urgent the doctor said because of the spinal cord involvement and I could not even write my name with my hand.

Anyway I am at the tedious process of appealing the Insurance companies decision. My doctor has already done a Peer to Peer review phone call with the Insurance and it was still denied. I guess I am asking has anyone gone through this process before regarding TLIF and the insurance reluctance to pay for a TLIF. And my doctor has said that is the only operation he would consider because that is what I need, so I am free to go to another doctor to have the laminectomy and fusion, but he feels I would be back in surgery within 2 years (actually those were the nurses words).
Bill H


  • I'm sorry. its scary to think you have a medical doctor with a 4 year degree a probably 5 year residency program and possibly a spinal fellowship and who knows how many years of experience saying what surgery is best for you while someone in an office without even an MD dictating what surgery you can receive. I hope you are able to get it all resolved soon.
    33yo mom of two. My surgical history...preadolescence scoliosis, kyphosis, and a hot mess.... 5 spine surgeries and lots of items added I wasn't born with (titanium, peek, surgical steel). Guess cremation is out. TSA loves me.
  • sandisandi Posts: 6,343
    edited 06/08/2013 - 4:23 PM
    the appeals process can take some time to get through. Due in part to the large increase in surgeries for the spine in the last 10 years or so, and the increasing failed surgery diagnosis', insurances are demanding reasons for the particular approach being used. I 'm a bit surprised that they are balking at the TLIF approach since it is damaging to less muscles than the traditional PLIF approach.
    It may be that the code used is wrong- which may be why they are insisting on the laminectomy, - is it possible that they believe the main problem to be stenosis , rather than the removal of the bone spurs and spondylolysthesis? I would start there and make sure that the diagnostic codes are correct, and then talk to your surgeon about furthering the appeal.
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