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Insurance deems not medically necessary

rlobo2rrlobo2 Posts: 4
edited 10/18/2014 - 3:09 PM in Lower Back Pain
I received a denial letter concerning fusion surgery. Dr's diagnosis: 1) Lumbar scoliosis. 2) Multilevel lumbar DDD. 3) Lumbar central and lateral recess stenosis. 4) Lumbar foraminal stenosis.
I have had severe left leg pain both upper and lower, pain in my buttocks and lower back, and initially a shooting pain from my foot to my hip.
I have received 3 opinions from 2 Neurosurgeons and 1 Orthopedic surgeon recommending fusion surgery. I have been dealing with severe lower back pain for 8 months, 7 chiropractor visits, PT for 2 months, 2 rounds of facet injections and 1 lumbar injection, PT again for 1 month. I had scheduled the fusion surgery with a well known and respected neurosurgeon only to find out my insurance would not cover due to it not being medically necessary. Has anyone out there had issues getting their insurance to cover surgery or treatment? I'm a 59yro male that in the past was very active, mainly golfing and fishing and working out 5 times a week. Now I cannot walk around the block with my dogs due to leg and lower back pain. I have a sneaking suspicion that maybe my Neurosurgeon's office did not submit enough info on my behalf to the insurance company. The surgeons office has refused a peer to peer review and thrown it back to me to appeal and come back when I have the approval. Maybe I'm just turning into a wimp but I want to get off my pain meds and get better. Any suggestions from anyone? I'm just looking for some suggestions I guess on where to go from here.
Thanks for any feedback


  • sandisandi Posts: 6,343
    edited 10/18/2014 - 4:03 PM
    to change the diagnostic codes for coverage. In most cases, if the coding is incorrect, the insurance will deny the procedure.
  • I've spoken to insurance people over denied things in the past. They've always been really nice & told me what needs to change for approval. As Sandi says it could be a code. Sometimes more words need to be written or different words used. Sometimes they're lacking information. I've had surgery denied because my treatments hadn't been linked to my case...it looked to insurance like I walked in & asked for surgery!! I'd just phone them.
    Osteoarthritis & DDD.
  • my lumbar fusion was denied as well. we fought and the insurance company basically ignored me and my doc. they claimed it wasn't medically necessary, and were willing to cover the cost of a laminectomy instead. didn't want to hear reasons for why that wouldn't work. it also didn't seem to matter to them that i had already had 2 laminectomies in that same location, paid for by them, and they didn't work either. but it took complaining to their corporate offices to get my surgery approved. it was a whirlwind situation with approval 5 days before my originally scheduled surgery (which had already been cancelled.) thankfully OR spot was still open and they could get me in for pre-surgical testing on a friday before the monday surgery. but as far as my insurance goes, it is still listed as not medically necessary. but they paid the bill.
    Microdisectomy / hemi-laminectomy 6/2010 and revision 10/2010
    Cervical fusion C4-5 and C5-6 9/2011
    Lumbar Fusion L5-S1 6/2012
  • rlobo2rrlobo2 Posts: 4
    edited 10/27/2014 - 3:50 PM
    Thanks for all the helpful suggestions. I did talk to the insurance company and they offered to do a peer to peer review with my Dr, Guess what, my doctor declined and said he didn't have time. His office staff told me he is a highly respected neurosurgeon and he just didn't do peer to peer reviews. I have since switched to the 2nd Dr I sought an opinion from and he and his staff are bending over "backwards" to help me. What has our current health care system driven Dr's to? I will post again when I heard back from my insurance company. Good luck to all the upcoming surgery candidates and I hope you have a speedy safe recovery!
  • I completely understand what you are going through! I have had to talk to my insurance 4 times to get them to approve my surgery that will be on October 30th! They have finally just approved it. I am sorry to read you are having issues! I am glad that the second doctor is bending over backwards to help you!! I pray you have an easy recovery!
    L5-S1 Emergency PLIF Revision May 26th 2015
    L5-S1 PLIF May 22nd 2015.
    L5-S1 Discectomy Feb 27th 2015.
    L5-S1 Discectomy Oct 30th 2014.
  • Blue Cross Blue Shield denied surgery at last minute. The sited that the physical therapy notes not received. My doctors office has the receipt information for the fax. All pages were received. My company tells me it is a tactic to exhaust all other options. I've been almost unable to walk for the past 5 months and my doctor tells me I need a fusion because of the joint moving. I'm in sales and the pain has really been awful.

    My doctors office has appealed and I have been calling my HR dept at work... This is a nightmare.
  • first of all, you are not a wimp..at least not intentionally. pain makes everyone a wimp! second of all, i would be furious if my dr refused a peer to peer. i actually recently had an argument with my neurosurgeon because the office didnt do a peer to peer BEFORE a denial(i was advised that it may get denied and it would be faster to have the office do the peer to peer first so i didnt have to wait any longer and be in more pain). the office got the hint, and did the peer to peer..or it got approved anyway, idk.

    but if an office refuses to do the peer to peer i wouldnt do surgery with them...find someone who cares about you!
  • I am so glad you moved on to a different doctor. Refusing to do a peer to peer would be a huge red flag! If he doesn't have time for that I would really wonder if he had time for proper care. My surgeon completely disagreed with the radiologist report from my last MRI so he actually sent his report when getting approval for surgery. It was approved within a few days. Hope you get answers soon!
  • I hope you are finding a doctor that is helping you. Maybe a second opinion from another office might be necessary. I don't think your doctor doesn't "care" just because he doesn't have time to do the extra paperwork...Neurosurgeons schedules are crazy! That being said, some insurance companies will sometimes deny a surgery if they think another less invasive surgery is medically necessary....did they say they would cover another procedure? Maybe they don't think you are ready for a fusion yet? I know its frustrating....luckily my fusion was covered right away, but I do have to fight with my insurance company about things like meds, and its so frustrating....Also, getting another surgeon on board saying you need a fusion would prob help push things along....Also, have you gone through all of the less conservative methods? That would be another reason for a denial...Most will make you do PT, injections, medical management therapies first....
    Spine-Health Moderator 
    Ankylosing Spondylitis
    Bulging discs T12-L3
    Annular Tears with Disc Extrusion L4-S1
    Moderate Central Canal Stenosis
    Moderate Foraminal Stenosis
    Enlarged Facet Joints/Ligaments
    Spinal enthesopathy
    L4-L/5 PLIF with cages, rods, screws 2/15 

  • After 3 denials and at the highest level of appeal, I thought "I am just beating my head against the wall" because the insurance company only used the initial report from the first radiologist despite having several doctors who contradicted the report. The orthopedic surgeon never documented incontinence either. I met all six criteria for surgery and I clearly had a compressed nerve. I decided to get another opinion from a neurosurgeon to know for myself because the insurance company almost had me convinced there was nothing wrong with me or that I had something else like MS. Because of the incontinence I was able to get an emergency appointment with a neurosurgeon and after examining me and looking at my images he said he had to do emergency surgery. When I inquired about insurance he said he didn't care about insurance, I needed immediate surgery. His exam confirmed nerve involvement and his report stated it was an emergency situation to avoid permanent damage. I did have incontinence that was worsening, which made a difference. I think running me through ER helped. I don't think any preauthorization was obtained but my surgeon was on my preferred provider list. My doctor was paid but I am still waiting to find out about the hospital. At the time of surgery, I decided I could not go on the way I was and would just file bankruptcy if I had to.
  • So you got a date? That's great!! Please keep us updated on your surgery...what kind of fusion are you having???
    Spine-Health Moderator 
    Ankylosing Spondylitis
    Bulging discs T12-L3
    Annular Tears with Disc Extrusion L4-S1
    Moderate Central Canal Stenosis
    Moderate Foraminal Stenosis
    Enlarged Facet Joints/Ligaments
    Spinal enthesopathy
    L4-L/5 PLIF with cages, rods, screws 2/15 

  • What a nightmare you are going through and having to battle something like
    that is only worse. I am currently fighting for payment of PC urine tests.
    The Neurosurgeons should not take on patients if they cannot take care of
    their needs busy or not, unacceptable excuse. I had a Doctor who stayed until
    midnight one time to do a justification for a medication to send to my insurance.
    Hopefully you will find a Doctor and treatments whatever they maybe to help you.
    Best wishes
  • rlobo2rrlobo2 Posts: 4
    edited 07/25/2015 - 3:26 PM
    Been offline for a while and my saga continues. Surgeon recommended taking as many insurance conditions off the table so I have had an 8 week course of "Cognitive Therapy" and 10 more sessions of PT. Prior to the PT I asked my pain specialist for more shots or something because my pain was becoming much worse. They recommended an RF Neurotomy (nerve burn) and that was done in May. Took awhile but my pain was manageable again and my surgeon submitted for insurance approval for the fusion surgery again because the Cognitive Therapy was now off the table and he was convinced he could talk to the insurance company and get approval. Guess what? Denied again and now the insurance listed some new conditions, I pressed the surgeon for the peer to peer and he stated he was done wth me. Its was obvious to him the insurance would approve my surgery and he would not waste any more time with me. Then I found out he was leaving the practice he was in and relocating. Now I am back to square 1 and beginning to question everything again, after spending hours researching spinal fusion I am more confused than ever. Can anyone suggest where I turn now for some qualified advice. I have 3 different surgeons all recommending fusion surgery ( 2,3 or 4 level fusion), should I get more Dr's opinions? My insurance co sent a new letter stating they would approve a "Removal of Spinal Lamina" and before my surgeon quit he said that would only destabilize my back and cause future problems. He absolutely would not perform that surgery! So how come the insurance company would approve a surgery that would only lead to more problems for me????? I'm now lost, confused and scared. Any help or suggestions from the forum?
    Thanks for listening!
  • dilaurodilauro ConnecticutPosts: 9,864
    The insurance companies have a lot of say into what will happen and wont will not! Its not always the pure medical evidence that decides what is going to happen.

    It really is up to the doctor to provide the insurance company with all the rationale and justifications. Once the doctor is convinced that their action plan is solid, then they need to do whatever is necessary to make that happen.

    So much of medical insurance today is done by medical coding (CPT, ICD9, ICD10, etc) The right coding needs to be communicated to the insurance company for approvals and reimbursement to happen.

    A simple example. I recently had Achilles Tendon reconstructive surgery. For the first 7 weeks, I had to exist in a non-weight bearing environment. So, the answer, was a knee walker/scooter..

    When I submitted the claim to the insurance company they took that code ICD9 905.8 Late Effect of Tendon Injury[/u] and translated that into claim code E0118, which is defined as a [u]Crutch substitute[/u]. That then resulted in a insurance reimbursement for a $125.00 rental into .85 cents payment!

    I then talked to the doctor and resubmitted the claim, this time using ICD9 727.7 [u]Rupture Achilles tendon surgery, non traumatic
    .. This time the insurance company reimbursed $85 for the exact same rental!

    Shows you had different numbers make all the difference in the world.
    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
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