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Surgery Denied

I just found out that my surgery was denied a 3rd time, Blueshield PPO, doesn't feel that it is medically necessary for me to have it. I had all the tests that they suggested (MRI, CT) Ive exhausted my PT for the year, I can't have NSAIDS including cortisone shots. But they will keep paying on paying for me to have Percocet and Somas grrrrrr I am so dumbfounded by this. Has anyone gone through what I am, and won?


  • 1028761102876 Posts: 248
    edited 07/08/2014 - 6:33 PM
    I have a few times with a different insurance company. Are you given a case manager? I have found that has been extremely helpful because you can tell them why it is needed and Ben have your surgeon call them directly. We also called to referral office about it and appealed the denial ourselves writing why it is needed and my past. It took a while but when something is needed then you just don't stop pushing for it.
  • Thank you for your comment, Yes, I was given a case manager, unfortunately I didn't have any luck with that. I don't give up very easily and Im sure there are alot of peeps out there that might given their circumstances I am going to file an IMR, and my original back surgeon is also going to write up a letter stating why I need this surgery. The percocet has started to not work as well as before, so my doctor gave me some oxycodones 30mg...ugh I know its very similar to what I was taking but it makes me feel so weird. Im thinking of cutting it in half and see how it affects me then, but it does a great job at taking the pain away..
  • the insurance company offered to pay for a laminectomy, claiming the fusion wasn't medically necessary. of course they ignored the imaging reports (solely based their deicsion on the 1 paragraph written report from the radiologist) ignoring other parts of the report, and the images that clearly showed why my surgeon wanted to do the fusion. they offered a laminectomy, even though they had paid for 2 previous laminectomies in the same location, with obviously poor results.

    anyway, doc wasn't getting anywhere trying to talk to their peer review person. (doc would never get on the phone with him.) so we complained. written complaint letter sent to 7 top execs in the company.

    i guess the right person read it. got a call the next day saying they were approving my surgery and then called my surgeon's office to give him the approval as well.

    the person from the insurance company who called my doc told the office, she had no idea how i got it approved since the approval came form the corporate office instead of the doctor's review section.

    in the complaint, i had documented everything i had already done. explained they already paid for 2 laminectomies. explained the results of the MRI and CT scans i had. reminded them, they stopped paying for PT in my case a long time ago. I had tried the meds, the shots, PT etc. I also pointed out my doctor was being given the run around with the peer review line. And they did listen. had my sugery date reinstated and went for surgery 5 days later.

    Funny thing, my doc was presenting a paper at a conference between the denial, and the complaint. well, he wanted another opinion, so showing an image from my MRI to a room of 200 other docs, every one of them agreed, i needed the fusion. but insurance will stay maintain it wasn't medically necessary.

    i'm sorry you are having the problems. insurance is always looking for a way to save money, regardless of what the docs and the patients think or need.
    Microdisectomy / hemi-laminectomy 6/2010 and revision 10/2010
    Cervical fusion C4-5 and C5-6 9/2011
    Lumbar Fusion L5-S1 6/2012
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