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Anyone have DDD fusion surgery paid for by Blue Cross Blue Shield?

Well, as the subject says, does anyone have any success stories to share with having your insurance company pay for lumbar fusion surgery for DDD? I've read some stories about long appeals taking two years plus. Anyone have an easier path to this? Does a surgeon have much leeway in influencing the insurance outcome?

Thanks in advance!
3/11/13 successful ACDF
7/13 inconclusive discogram
Currently in PT for lumbar pain


  • I work in a hospital business office( lots of insurance experince)and I had surgery last month. I have BCBS and they approved my surgery within a couple of days, no appeals done. But I had spondylitis, inflammation in my bones, pars fracture etc. basically my spine was unstable.
    If you have any stenosis, compression of your nerves, I think they will approve it for that. I had a 2 level L4/L5/S1 360 fusion( from the front- ALIF and the back PLIF.
    I would ask the doctor next time you go and let them know your concerns!
    99/00 L4/5 & L5/S1 herniation
    2001 L5/S1 microdisectomy age 25
    severe DDD at surgery level
    2011 pars
    2012 RFA L/3/4/5
    7-02-13 L4/5 l5/S1 360 fusion ALIF PLIF
    DX spondylitis , DDD, scoliosis, and slight kyphosis
  • Thanks for your input! I looked online at my BCBS coverage and they seem to be very strict on what is allowed and what isn't. Some of the procedures I have read about here (microdiscetomy for one) are not covered for any reason as they are considered experimental. There are very strict policies regarding lumbar fusion. My doctor is the one who mentioned that BCBS can be "tricky" about approving fusions. He had me have a discogram a few days ago (don't even ask-I'm still recovering) which I guess will show nerve compression.

    It was odd reading the BCBS policy standards. I had ACDF surgery in March and according to what I read that should not have been covered. Who knows though. I'm starting to realize that there is A LOT that goes on behind the scenes at doctor's offices that patients (at least me) have no idea about.

    I read through your list of surgeries- are you feeling better? My heart and prayers go to you.
    3/11/13 successful ACDF
    7/13 inconclusive discogram
    Currently in PT for lumbar pain
  • I had plif L5/S1 on 6/12. First denied by BCBS, then approved after peer to peer consult. They wanted to be sure I had exhausted all options first. PT, injections ect. I had severe DDD and S1 nerve root compression. The surgery was a complete success! I was told 50 - 60% success rate. My back feels so much better! Good luck!! BTW they also approved my 2 level ACDF 5 weeks later.
    PLIF L5/S1 fusion 6/12/13
    ACDF 5-7 7/17/13
    44 year old Mom of 10 and 12 year old girls, full time veterinary technician.
  • I feel better, about 85-90%. I start therapy soon and hope to be 99-100%.
    So there are bcbs Texas, Oklahoma, and Illinois that are kinda "shared".
    If you having something different then the policy can be very different. They don't want to pay for just DDD. But my dr listed that as my primary diagnosis. They will pay for it if your spine is unstable. I think there are 3 conditions they'll pay. Did your doctor say you only had DDD and nothing else wrong?

    The discogram will tell them what is going on with your disks. Mine showed tears and they grade them, I had some level 5's which is the worst. Did you have a CT afterward? My ct showed a scoliosis curve that the mri didn't.
    Have you gotten the report from the dr?
    99/00 L4/5 & L5/S1 herniation
    2001 L5/S1 microdisectomy age 25
    severe DDD at surgery level
    2011 pars
    2012 RFA L/3/4/5
    7-02-13 L4/5 l5/S1 360 fusion ALIF PLIF
    DX spondylitis , DDD, scoliosis, and slight kyphosis
  • I got approved right away for Alif L4L5S1 FRONT AND BACK.
    Kathy B
  • They usually will approve right away if you have any instability! If you don't they generally require more tests to make sure that is the problem of your pain such as a discogram. Hope this helps.
    L5-S1 anterior/posterior 360 fusion Aug 2013
    Grade 2 spondy, Severe DDD L5-S1
    L4 Facet arthritis
  • Hi all-
    I had a discogeam and CT scan on 8/15 and will probably have an appointment with surgeon to go ob er results this week. The discogram was sickenly painful. Apparently the doctor haf s reslly hard time getting the needles in two of the disc spaces. The pain was the worst I have ever experienced and frankly I didnt know the body was capable of producing this level of pain.

    My surgeon is kind of vague about assigning a specific diagnosis. I have read over MRI reports to determine what's wrong: ddd at several levels and facet problems, from what I recall.

    Since the discopain was so excruciating, does this show nerve impigement? As far as stenosis goes, the reports all say no significant stenosis.k

    I am in NC and NCBS says they will only pay for cancer, spinal tuberculosis, and severe instability. I'm not sure if I even want surgery but it's nice to know insurance will pick it up if I need it.

    Do discograms "verify" conditions to indurance companies?

    Thanks everyone! !
    3/11/13 successful ACDF
    7/13 inconclusive discogram
    Currently in PT for lumbar pain
  • BentechBBentech Posts: 64
    edited 08/18/2013 - 7:13 PM
    Were you sent for a CT right after the discogram, they pressurize your disc and inject a dye if you have severe pain durning the discogram they should send you strait away to CT to have a look at the tear! The idea of the discogram is to duplicate your normal pain so they know what to fix.
    L5-S1 anterior/posterior 360 fusion Aug 2013
    Grade 2 spondy, Severe DDD L5-S1
    L4 Facet arthritis
  • inchwormiinchworm Posts: 719
    edited 08/19/2013 - 12:26 PM
    Like others who have commented, I was approved for fusion by BCBS but my diagnosis was more complex than simply DDD--radiculopathy, scoliosis...

    In my experience, the wisest thing to do is get pre-approval for any surgical procedure. If you have any questions, call BCBS and ask them what to do to get approved. In my case, my surgeon had to submit his surgical plan. With the changes in insurance coverage taking place, you can't be too careful when it comes to assuring coverage. Of course, everyone will likely have different coverage with their individual BCBS plan.

    2009 Foraminotomy C6-72010 PLIF L4-S1Multi RFA's, cervical inj, lumbar injLaminectomy L3-4 and fusion w/internal fixation T10-L4 July 17Fusion C2-C5 yet to be scheduled
  • I had BCBS of Tennessee when I had my fusions last year. Took less than a day to get approved for all my surgeries. Now I have BCBS of Alabama, they are so slow. My NS wants to have a spinal cord stimulator trial, it took them a month to send me a letter saying it was pre-existing. They have paid for all my back stuff including injections without ever saying my back issues were pre-existing. The insurance company didn't approve or deny my SCS trial, the nurse is going to file it again in December when my pre-existing conditions clause has lapsed. She said it probably won't even take a day to get approval at that time.
    Discectomies 05/08 and 04/11, fusions L4-5 Feb 9,2012 and L3-L4 June 28,2012, Staph infection washout 3/2/2012, Bulged L5-S1. SCS trial on January 17th, 2014, which was a success! Permanent SCS on February 20th.
  • Well, the discogram (or disco-worst-pain-in-the-world-a-gram) showed annual tear in l4-l5 and many holes, spaces, whatever, in L5-S1. I did have a CT scan afterwards.

    My NS called me Monday morning to discuss the results and told me I had a decision to make regarding having surgery. He caught me so off guard by calling me, that all the questions I had been mentally compiling immediately flew out of my brain. I told him that I did not want to have surgery and he suggested aggressive physical therapy, seeing a PM doctor, and switching to long term narcotics. He said that surgery was something I might feel better prepared to handle at a later date.

    That whole day and the next I contemplated what he said. I picked up my new med (Opana er) which did nothing what-so-ever for my pain. Without the short term narcotics that I have been on off and on for so long, all the pain came back with a vengeance. All the lower back pain, the hip pain, the absolute inability to sit and pain in my tailbone. The thought of going to PM and learning to "manage" the pain without any real possibility at fixing the problem, the pain and expense of PT (been there, done that three years ago for the same issues) and then the thought of STILL having to have surgery sometime in the future, made me really depressed. I am a "plan of action"type of person- the thought of being in a type of limbo for the indeterminate future is one I don't want.

    I am already on short term disability, I have almost met all of my out-of-pocket costs for this insurance cycle. Therefore, the timing for surgery is good. I am a teacher and have been so depressed about not starting the school year- the first time in 15 years that I have not been there for those first staff meetings and excitement. After I thought about all of that, and talked it over with close family and friends, I realized that I would rather have the surgery now. Take care of these problems now and focus on getting better. Be back for the first day of second semester better than new!

    (I know that I am being optimistic and there is a chance this won't do a thing, but a gal can dream can't she ;D ?)

    So, I called NS office back and he called me that evening. I told him everything I had been thinking, and he said that even though it was my decision, it all made sound sense.

    I am scheduled for three weeks of PT which start tomorrow evening in order to satisfy the fusion insurance requirement that all conservative methods have been tried. In three weeks I meet with NS for surgical plan and scheduling.

    He told me to stop taking the Opana er (wasn't doing crap anyway) and move back to Norco 5/325 as he wants my opiate tolerance lowered. This way the post-surgery pain can be managed better. This kind of sucks as the pain is pretty bad, but I totally get his logic.

    What do you all think? My mind is made up, but I would appreciate feedback. This site has been invaluable for me for months now and any words of wisdom/suggestions all give me talking and thinking points.

    And then of course, there is the small possibility that three weeks of PT will fix it all...uh, is there a chance????

    Thanks in advance, and I will keep you updated. I am nervous yet excited to finally have a plan!

    My NS doesn't see insurance approval an issue even though I do not have significant stenosis or the other more severe conditions. I guess he knows best- I would really hate to be one of those people who on the day of surgery be told at the very last second, "nope- BCBS of NC denied it." I can't imagins any NS worth his salt would not get pre-approval in the first place.

    Good night everyone- you don;t know all the support all of you have given me.

    3/11/13 successful ACDF
    7/13 inconclusive discogram
    Currently in PT for lumbar pain
  • RTgirl-
    Let me make sure I have this right:
    You have had lumbar spinal surgery, but it is not fusing correctly?

    How on earth could *they* think that your condition wasn't pre-existing if they had approved and paid for fusion?? As soon as I hear a crazy insurance story, sure enough, one comes up and tops it!

    Is the spine stimulator considered investigatory? Is that why it is a problem?

    Do you mind me asking what the problem with the fusion is and why you need the stimulator? Best of luck to you- it sounds like you have had a long battle. You deserve relief and access to the best procedures available.

    Yes, they did a CT scan directly afterwards.
    My major pain, totally unbearable actually, was when the radiologist was inserting the first needle that accepts the dye needle. In both places, L4-L5 and L5-S1 the space was so narrow and tight that he had a very difficult time even getting a needle in the space. What does this suggest, if anything?

    When he actually put the dye in it wasn't too bad, about a 7-8 at the higher level and 3-4 at the lower. The higher showed an annual tear and the lower just a very deteriorated, porous disc. The NS was surprised as he thought the lower disc would be a bigger pain generator.

    Do you know anything about this reading?

    All of you, thanks for the input and I'm so sorry for your issues- especially those of you with such serious stuff going on. It makes me feel whiny for complaining about my own pain. You are real heroes!

    3/11/13 successful ACDF
    7/13 inconclusive discogram
    Currently in PT for lumbar pain
  • Each BCBS "franchise" has its own rules, set forth in their medical policy. These are usually easily found

    I had no problem getting approval for a two level lumbar fusion with instrumentation, four days hospital stay, a pile of PT appointments and a bone stim.

    I did have a several month history of MRIs, failed PT, epidural injections, etc. and my surgeon's staff is well versed in knowing the magic words to placate the big blue monster.

    Frankly, the bone stim sounds like woo to me, but if BCBS is willing to put out the $6000 for one, they must be useful.
    August 2013 C7-T1 MED
    July 2013 L4-L5-S1 TLIF
    December 2011 C5-C6 ADR
    April 2009 L5-S1 MED
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