Does anyone have any information about Medicare adding coverage for minimally invasive fusion surgery of the S-I joint ("SIJ")?
For the last 4+ years, I have been appealing the denial by Anthem Blue Cross for SIJ fusion (using the SI-LOK system developed by Globus Medical). The procedure is unlike other spinal fusions. For example, I am fused from C3 to T1 (with titanium plate, 9 screws, donor bone grafts). These were performed first at C3-4 and C4-5; then extended 3 more levels to T1 following a car accident 8 months post-op. Each procedure involved a 4-5 hour surgery and 5 days in the hospital. By contrast, the minimally invasive SIJ fusion is done through a small incision (1" to 1-1/2") on the side of your butt cheek & the surgeon places 3 pins into the joint, with bone grafts. It takes about an hour. Initially, patients were kept overnight for unilateral SIJ fusion and two nights for bilateral. As techniques improved, hospital stays were reduced to one night for either. And according to my surgeon, if you are "gritty" and your surgery is performed early in the day, some patients are released later the same day.
With all that said, when my surgery request was first sent to Anthem for authorization, approval was anticipated based on the number of past approvals and also because I had numerous objective findings -- all confirmed by MRI, diagnostic injections, second opinion from a reputable neurosurgeon at UCSF. In fact, many Anthem patients with symptoms less severe than mine were getting approvals for SIJ fusion. Back then in 2010, Anthem's policy ("EOC") was silent as to SIJ fusions. Denials were based on the wholesale, rubber stamp reason we often see, i.e., "this procedure is considered to be experimental and investigational." It wasn't until April 2012 that Anthem adopted specific language in its EOC which provides coverage for SIJ fusion(s) under one or more of the following conditions:
(4) Failure of prior arthrodesis above the SIJ
As so many of us here know, there are other reasons for SIJ disruption and the resultant debilitating and disabling pain. In my case, I have been told that my SIJ is "shredded" and so severely disrupted that therapeutic injections will not help. This was confirmed twice when the medication injected into the joint leaked down the inside of my leg and left me completely numb from the groin to my ankle, unable to walk for 8-10 hours while the Novocain wore off. This leaking is called "extravasation." Likewise, the cortisone injected into the joint leaked out, providing no relief whatsoever.
But moving along to coverage issues, I heard that once Medicare provides coverage for a specific condition, then private-pay carriers follow suit. After going through years of internal appeals within Anthem (as required by the policy), an administrative trial, etc., I am now at the point where I have to decide whether to pursue this matter in the Superior Court. Pursuant to Anthem's policy, an insured cannot file suit against Anthem until you have exhausted all of your administrative remedies under the policy. Anthem drags out this process for so long that I believe Anthem hopes its insureds will just give up and go away. According to my surgeon, no other patient within their group has ever taken an appeal this far through the process.
I am interested in hearing from any of you who have been involved in litigation against Anthem for denial of coverage for surgery/fusion of the SIJ -- or from anyone is familiar with this new Medicare policy that provides coverage for the newer, minimally invasive SIJ fusions (such as SI-LOK or iFuse, etc.)
Also, is it customary for private insurers, such as Anthem ("the Blues") or United Healthcare, et al., to adopt the same coverage allowances as Medicare? If you can provide a link to any substantive decisions or provisions by Medicare that have, or will, go into effect in 2015, I will be eternally grateful. I have researched this for hours and have been unable to find anything specific to approval of SIJ fusions for conditions beyond those already mentioned.
Thank you for reading through this. Any information will be greatly appreciated!
This is the type of information you need to call your Insurance company about. Different areas use different medical billing codes. Medicare has one set of guidelines, other Insurance companies have others.
So much depends on how it is billed by the hospital. Your first call should be to Medicare to discuss the options and found out from the Hospital what are the exact billing codes for the surgery Ron DiLauro