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surgery approval update

JulieAJJulieA Posts: 1,420
edited 06/11/2012 - 8:18 AM in Back Surgery and Neck Surgery
As some of you know I am waiting for approval from the creepy insurance company.... (see old site)..

I sent an email to another company employee(in another state) who had the same surgery 6 months ago and she called me to tell me her story.

The Insurance creeps made her get a second opinion and then didn't want to accept it. She was denied twice before they finally approved hers.

The good news is that they have already sent my file to the NS who approved her surgery and was her 3rd attempt.

Does that make any sense?

She said that I am not alone in thinking that these people are creepy and _itchy.

The conversation made me feel better. :sick: I have been depressed and angry all week and I have been trying to cheer myself up.



  • Sounds like you are making at least some pregress with it Julie. i do not envy those of you in the civilian sector. That's one good thing about the Military if a civilian doc says you need surgery its usually approved within a few days. Just keep your head up and things will get better.

    Hank 8)
  • Hi Julie,


    I'm so sorry it is taking so long! I know what it is like to have everything set and then rug pulled out from under you at the last second. Keep calling, keep praying and don't lose hope. It will happen. I'll keep saying a prayer for you that it happens soon. Best of luck.

  • Julie,
    I hope that you get that approval soon! That is so creepy and awful! :jawdrop:
  • As I sit here crying, I am so angry and depressed.

    I called the creepy insurance company to see if they heard anything. Of course they said they would call me but they didn't (I am long distance and they are cheep. She said that I didn't meet the criteria for such a surgery..... That I need to have a nerve conduct test done and reviewed by a Neurolagist, second and (even third opinion sometimes). This NS is the third doctor I have involved- I really like him and trust him. The others were my PC, the Spine Interventionist ((he does injections & discectomy)), 2 chiropracters,1 MT, and 1 PT........

    I hung up on her because I was crying so hard I was afraid I would have another panic attack....

    I called my NS's nurse and she said we can't do anything until we see the letter and instructions.

    I called back shortly and asked her to send by email the denial letter and the appeals forms.

    She said I would have it by 5 pm pacific standard time. Needless to say I am an emotional wreck. My husband isn't talking to me these days and when he does he isn't very comforting or supportive.

    I think I will go to a movie now. Take my mind off all this crud.

  • Awwwwwwwwwww Julie,
    That is so awful! I am so sorry I wish that we could mention the names of insurance companies in the open here so you could bad mouth them!! :( And anyone that has that insurance can cancel the heck out of them! Is there anyone that you can call? an insurance commisioners office or something like that? Is there someone that we can all write letters as spiney supporters?? Please find out! We will help you in any way that we can!
  • I got the stupid #$@^&*(*^&%# letter and appeals information and appeal form.

    Basically they are saying that we can appeal it right now, or get another NS/OS recomendation, or see a Neurolagist and have a nerve conduct study..... I have a feeling that my NS nurse may not have sent them the xrays that shows the severe retrololishsis (sp). The xray report didn't mention the retro- but was very obvious to my NS on my films. I think she just turned it in as a hernaited disc.....

    I don't know what to do and I feel like this is out of my control. Hopefully Monday will bring better news.

    I am so sad right now. The thought of being like this for 2 more long months is killing me.

  • Julie,
    I understand your frustration, but this just seems so freaking unfair! So they want you to get an EMG? That is just so crazy! Have you had a Disco gram or any other test like that? Maybe these morons, will see it! The Disco is a kind of painful test but it is a very definite answer for surgery, ask your NS or another Doc to get you one. I had an MRI, CT, and Myelogram and the Disco was the final answer to corroborate that I needed surgery ASAP. Hope this helps.......... Hugs,
  • I don't think I need the disco or emg (but I will have them if they help). I have terrible instability as seen on my xray- S1 is pretty much completely dislocated from L5- where it does touch is bone on bone. That disc is very thined and has a central herniation pressing on the thecal sack. The one above is herniated with an annuar tear to the left (I think).

    As my NS said my discs are not that bad but the spine is terrible- he felt that we needed to have surgery sooner than later.

    Thanks for the Hugs- * hugs back*

  • I am just thinking on what else can help this idiots make the right decision! I know that BCBS wanted one to confirm that I had 4 major herniations and stenosis and everything else that I had, even though my Doc just fused 3, but that was enough for me!
  • I started re-reading the denial letter late last night and after reading about the appeal process I realized that they didn't tell me why I was denied only that the outside NS (the one they pay to say NO) said he felt it wasn't medically necessary.....

    So I asked for all of my records that my NS's nurse sent them and the the records for the denial. I need to see what was presented and what was the reasoning for the denial.

    It is possible that they didn't recieve all of the pertinent information from my NS's office.

    In all fairness to these "creeps" they have paid for everything else ay 100% since March.

    My evil side says if it is not medically necessary then I probably do not need to wear the huge brace any more- right?

    I am considering not wearing it this weekend for my yard work and dog training. Usually I take it off after it gets hot and sweaty and put on the dry one that is not as stiff.

    I wonder what would happen if I don't use it at all?????


    PS/Feel Better Millie.


  • Good Julie,
    I am glad that you read the letter and that you e-mail them. Sounds like a great idea to make sure that they received every little single detail from your NS's office, hopefully something was amissed here. Thanks for wishing me well, I am just having one of those stomach things that keeps you next to the bathroom and with a bucket next to your bed! :sick: Take care,
  • I wish I could name the guy who denied my PLIF. I did a search on the net. God this guy likes to say NO. He is all about saving money. He also likes to see his name in print. Eeeegads :sick: :sick: :sick: ...... Interesting that I was told he is a board certified NS, but no where on his resume does it say NS. He has history as a medical director and an emergency room doctor. His company will be your insurance company's medical director for a fee. Neato!

    I wrote him a note on the contact page of his website asking for my records so I can see if we may have missed some information on our side. I doubt he will reply but ya never know.

    I also sent myself his full resume. If any of you want to see it I can email it to you.

    PS/ I mowed & bagged the lawn with our my brace and haven't taken any pain meds yet. I am hanging out around level 6 today. Sitting on my heating pad.

  • JulieAJJulieA Posts: 1,420
    edited 06/17/2016 - 12:25 PM
    I researched some more today- there is nothig coming up as him being specialized as stated in my denial letter. I also called the insurance company again & left a message with the nurse manager on my case....

    Here is a link to check your doctor. 

    You will have to register first.
  • Hi Julie,

    Thank you for the link! I am so sorry you are having so much trouble obtaining approval. It seems this system or this horrible mand just are giving you the run around.

    Too bad you can not talk to someone face to face and image

    I hope you have something there with this guy not even being a NS.

  • I just spoke with the Nurse Manager on my case and she is literally illiterate... She was speaking in circles..... I abused her a little and then hung up on her after telling her Thank you for nothing...... I brought up the fact that Dr. "fudge" was not board certified in NS and that I couldn't find anything on him.

    She told me thye "never" approve a fusion with out a nerve conduct study- ever..... ever...
    She told me my NS never mentioned any weekness or nerve pain in my legs.... She was looking through the reports.... He did mention the retro on spondy but the xray report did not mention it....

    She told me to speak with my NS directly- I have a call into the nurse- I tried to make an appt but the receptionist didn't think I needed one- just to wait for the call back.

    My goal today is to get an nerve conduct test scheduled.

    This is kind of my online notes at this point sorry if it
    is inappropriate for this board....
  • image Oh Julie! I have been out of town - no internet. :jawdrop:
    What a bunch of image! My NS made me get an EMG before my micro. How dumb it was - $1,400 later..... "you have nerve damage". Well, DUH! Where's the little dude with the hammer? image There we go!

    Keep us posted.
  • I would talk to your doctor directly and not to the dingbat nurse.
    image So completely inapt.
    Good luck with your report. Please let us know how you are doing.

  • What a bunch of crock! :jawdrop: I agree with Smurf, you need to talk to the Doc directly, he knows this process, he should know how this works and all the redtape involved! If this is his first prom he has an issue too! Don't give up sister, you will prevail!! Spiney's are tough and you are a tough cookie!! BTW thanks for the website.


    Millie ;)
  • Hey Julie, sorry I somehow missed your recent postings on this. I've been in and out checking the boards. This is awful! How can these people live with themselves? This is not a rhetorical question.

    I'll PM you the name of the Doc who previously did my EMG and nerve conduction tests (both cervical and lumbar at various times). She seemed to be pretty good. The testing stings a bit, but compared to the nerve pain I already had, not too bad. Just different. If it gets you past the imbeciles that are denying you coverage, it will be worth it. And hey they are making you do some more expensive testing to prove a point you already know to be true, since it sounds like you have nerve pain and identified deficits. If they want to waste $$, so be it.

    I'll also send you the link to the State medical insurance commission. Don't know if they are any good ... actually I have doubts. One of their "headlines" on their splash page is about an issue from 2004. But who knows, maybe worth talking to if you don't get any satisfaction.

    Have to agree with some of the previous posts. If you like and trust the NS, that may be your best advocate with the insurance company. Otherwise, just jump thru the hurdles you need to to get the care you need. Unfortunately this will cost you time.

    BTW ... Have you seen the movie "Sicko" by Michael Moore? Should be required viewing for any spiney. If you haven't seen it, you should. I am grateful I didn't go thru this type insurance nightmare, but what that movie makes it perfectly clear is that for most of us in the U.S., any of us could experience this kind of treatment when least expected. It is a tragic shame we don't have a decent system that worries about patients more than profits.

    I hope you can enlist the help of your Docs to work on your behalf. And hang in there!

  • AKguy- you are not set up to recieve private messages. I think I have an email for you so I wil reply to you via email? Oops I don't have that either.....

    Smurf & Millie- Thanks, I know I need to talk to the doc,I will try again to make an appt. He may now want to waste his time on me since he already knows that I need surgery.

    Wish me luck today. I have a feeling it is going to be a good day. I actually slept in so that means I got some rest last night... :)

  • I watched the entire movie online for free... It is maddening. The whole reason I added the second coverage to my insurance was once I saw that movie and I knew I was under insured- I wouldn't be able to afford co-pays if a major health issue happened/like it is.

    The only problem is Moore makes it out that people in Great Brittan have this great public health care system when in fact they do not. It seems every person that posts on this board is waiting for months and months before they can even get an MRI or they have to pay out of pocket.

    I heard there is a new part 2 movie coming out and I will surely see it.

  • Dear Mrs Alvarez,

    I wanted to briefly share with you to provide clarification on the evaluation provided by the independent review company Allmed. Dr _________is the Director of ______ here in Portland. Dr. _______signs off on all reviews which were handled by Allmed, reviews which were performed by the various specialists. Your case was reviewed by an outside neurosurgeon. I double checked with _______, and this information was confirmed.

    I believe in our letter to you, dated June 27, 2008, this information was not clearly spelled out- in fact may have been confusion for you. We do apologize, it was not our intent to cause any concern.

    If your surgeon wants a peer review with Allmed, this can be arranged at any time.

    Please let us know if you have any questions and our apology for not clearly stating the above information.

    Thank you,


    I wrote back a nice note cc in my hr department. There was no confusion on my part It was purley fabrication on there part....

    Called my NS's office again- still haven't got an appointment or talked with his nurse (it is lunch time here).

    OK- I am off to run errands- Costo and Wallyworld if I can manage.

  • Julie,
    Your NS needs to come thru for you! They have probably received enough money already from your insurance company that they should get a darn clue! If I was you and is not to far away I will be in there office knocking on the door and be on their face until they helped me out, but then again I am a pushy Puerto Rican........ :O No, not pushy at all! kidding, just been jerked around by the system enough to know that only the really, really squeaky wheel gets oiled. Good luck and have fun shopping, keep us posted!
  • I spoke with the nurse of my NS and they hadn't recieved any information from the insurance company. We are scheduling a phone meeting between my NS and the infamous Dr ______ with the insurance company hopefully sometime this week.

    My NS nurse said the insurance company are idiots. I do not need the nerve conduction test at all.

    On a side note I went to my club dog training tonight and I had a little running to do (very little) and I totally felt like I was going to loose my legs. I am very sore tonight and have heavy duty nerve pain in both my legs/feet/hips/groin.... I thought I could skip the brace and I realized that I really need it. I hate this- I want my life back :(


  • Hi Julie,

    My god that insurance company is just horrible. image

    But I am glad you are finally having a meeting. :) That is good news that you do not need the nerve test.

  • Julie,

    I am sorry sorry for all of the s**t you have been going through lately trying to get your surgery approved. I have never heard of such a thing except with ADR. I'm praying for you girl! It sounds like you are doing all of the right things. Keep the faith, it will happen.

    I've been out of touch lately will some family stuff here but stay strong.

  • I received a certified letter from the Insurance Co today- In it was copies of every thing pertaining to my case. I looked through it and read the recent MRI report and X ray report- sure enough the x ray report did not menion the instability or the retrololisthsis at all.

    Then the NS reports did not mention much either.... I can almost see why the denial happened. I think the first nurse that I was with was a little incomplete with her paperwork.

    I called my NS office and was told that the NS had the peer review late last Thursday. Hopefully I will hear something soon.

    Thanks for your support.


  • Too bad the NS's shop didn't provide enough information to support the justification and need for such a major surgery right off the bat. I hope the surgeon made a good case, and you get a positive response soon!
  • Thanks AKguy. I re-read the paper work and looked up the codes.

    I had to look through the file many times to find this page. Instead of saying retrololisthsis grade 2 it says L5 spondylolistis grade 1 invloves the L5 vertbral body GLIDING POSTERIORLY TO THE S1 BODY this was in the notes from our 2nd visit after the last MRI and Xrays.

    Then it goes to another page and say:

    Lumbar Region Disc Disorder 722.93
    Degeneration of Lumbar interveretbral disc 722.52
    Spondlosis, lumbar 724.4
    Spondylolisthesis, Lumbat 756.12


    Now reading the denial from ALLMED they only reviewed the recent CT, the request, and the PT notes....... They never looked at the notes, the xrays, or the new MRI reports.


    I had a dream last night or this morning. My dream was that I received a call from the Insurance Company's friendly Claims Manager... In my dream I woke up right after she said "Mrs Alvarez we have your appeal and decided that" ...... Thats it. I woke up. My dog was barking in the back yard at a moose.
  • Hi Julie,
    really sorry about the situation.It makes me mad and scared!
    After 10yrs of troubles,my NS told me that I must have the surgery.Prior to last big herniation,I had tried all conservative options.Nothing helped.I had the surgery,but never bothered to get an approval from the ins. co.
    Your thread scares the hell out of me!I truly hope that everything works out and approval is on the way!

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