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I need Help

jskrubejjskrube Posts: 1
edited 01/29/2015 - 7:57 PM in Back Surgery and Neck Surgery
Hi
I have been told by 2 Surgeons that I need to have a fusion at the L5/S1 Leval because I have Internal Disc disruption and an annular Tear At L5 S1. I have done 1 year of physical therapy, 1 yr of chiropractic care, and 6 cortisone injections and my insurance company is denying my fusion surgery because they say my back is not unstable.

My disk is pushing on my nerve and causes pain in my legs which causes me to fall down alot. I have tried everything and nothing works.

My insurance company is united health care i have been appealing this for 1.5 year and they keep denying it. i need suggestions of how to get them to approve my surgery

Thanks
Jamie
Jamie
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Comments

  • LizLiz Posts: 7,896
    Welcome to Spine-Health

    Use that above hyperlink to help you get started with Spine-Health and navigate through the system.

    If there are any questions, you can always post them here, send Liz or myself a private message or contact Ron rdilauro@veritashealth.com

    Liz, Spine-health Moderator

    Spinal stenosis since 1995
    Lumber decompression surgery S1 L5-L3[1996]
    Cervical stenosis, so far avoided surgery
  • dilaurodilauro ConnecticutPosts: 10,045
    I would do is stop seeing any chiropractor.

    Once you have been diagnosed with a formal disc problem, you should be seeing only doctors that understand the spinal discs and spinal cord.

    Chiropractors have their place, but not in there. It is even possible for a chiropractor to cause additional problems.

    As far as your insurance company approving a surgery, that has to come from your doctor. The doctor provides the rationale and justification for any procedure, including surgery. If there is not enough substance in the doctor's approach OR if the doctor does not believe surgery is the answer, then that could be another reason why the non-approval. Talk to your insurance company,
    a back not being unstable is not a valid reason, there has to be more to it.
    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
  • itsautonomicitsautonomic LouisianaPosts: 1,933
    I have United Health Care plan and they usually have been pretty good with all my treatments, so many times its the way the doctor writes things up but yours seem to say you need the fusion.
    I have multiple annular tears and had good luck with epidural steroid injections targting the tears, avoided surgury in my case. Also in my case the doctor had no issues with chiro as long as the chiro knew what issues I was dealing with, took it slow and I knew that there was some risk involved and that I would stop if symptoms got worse. PT may also adjust your spine and I would say they have less training in spine than a chiro and have risks also. Its all about talking to your doctor first before trying anything involving the spine and understanding the risks, but that fusion also has many risks in itself.
    Do your due dilegence, trust you know your body and question everything if it does not fit. Advocate for yourself and you will be suprised what will be revealed trusting your body and instinct.
  • Dilaurio is absolutely right. You need to find a respected neuro/ortho surgeon and stop the chiropractor. They can much better help you treat your problems and talk with the insurance company about the medical necessity of the surgery.
    Christina
    Left leg radiculopathy/sciatic pain
    L5/S1 microdiscectomy - May 30, 2014
    L5/S1 microdiscectomy - Aug 14, 2014
    L5/S1 TLIF - Sept. 24, 2014
    Left-side screws/rod removed along with bone fragment Dec. 29, 2014
  • dkellyddkelly Posts: 4
    edited 01/31/2015 - 10:30 PM
    Jamie I have had the exact problem with my health care provider REGENCE. I have been suffering back since 2008 and have had numerous mri's, chiros and injections over the years. 2014 everything went from bad to worse and I had another MRI in May followed by injections which lasted 2 weeks each. August i saw my first neuro who advised I needed a fusion at L5/S1 and had suffered a traverse fracture at L3 which had gone by several other docs I had seen in the past. Thinking a second opinion was in order I went to another neuro and highly respected in the Pacific NW. Same but he wanted to do a disc replacement at the L5. Regence denied the surgery as "experimental" been going on in the US since 2004 and countries such as Germany and Canada much longer with great success. The denial was appealed with an anterior fusion(front) as well as fix some other damage at L3. Regence denied because it would require two surgeons, one to open and close and the neuro. 3rd try was for a posterior which was denied because there was no evidence given that I had been a non-smoker for at least 6 months, never smoked a day, I didnt show time away from work or daily disruptive activities, im in law enf i dont work I dont get paid,and Regence was provided with other means of spinal manipulation, I had 13 chiro visits and two injections in 2014. By the time I got the 3rd denial I had filed a complaint with the insurance commission of Washington which were not helpful a single second however did provide all documents that I had sent, my doctors had sent, and Regence had sent. This also included emails. Unfortunately while I was getting my research together a simple task at home ignited a fire in my back which left me without the use of left leg from the waist down. Transport to the hospital via ambulance and 40 minutes later I had word that the L4 had pretty much "exploded", not my word used but a doctor, and I would need emergency surgery. My new neuro was absolutely dumbfound by the delays I had gone through and 3 hrs later and a triple lam/discectomy at L3, L4, L5 / S1I am currently at home after surgery 10 days ago.

    To make this long story short and the help you seek this is what i discovered in the paperwork the doctor was sending to Regence. The request for surgery was all done on template forms with no narratives provided by the neuro. The appeals yielded the same forms with different procedures and codes but no narratives from a doctor explaining in depth the reason needed for the surgery and the suffering of the patient. Neuro staff had also gotten into email and phone spats with Regence which I have copies of also. There was nothing to indicate that the doctors at Regence who review whether a surgery is necessary ever got the actual discogram (die injection into lumbars) or EMG results (positive for nerve irritation/damage). I have been with Regence for 20 plus years and this has been my first request for anything other than a chiro visit. I learned from Regence that even though I have been a client they do not review prior history of the patient, only what is provided by the doctors for the case they are reviewing. Ask your doctor to see what is being sent to your health care provider in detail. Have all tests that you have experienced that has led to the finding of the surgery been sent to the provider?

    Though I feel better after the surgery, I am dealing with the post pain of the surgery. I am not even sure if this will fix all the problems I have experienced since my next visit isn't until later in the week. Good luck with your plight I hope this was of some assistance.
  • jlrfryejjlrfrye ohioPosts: 1,110
    Please PM me and tell what all has been submitted and done and I will guide you in the right direction. I agree with above, the Dr office is not submitting the correct information. It sounds like it will be up to you
    Susan
  • I couldn't imagine having to rely on Insurance when it comes to my health.... We simply don't get denied anything on a health level here in Canada.

    Being in a car accident and having to deal with my Auto Insurance has been a hellride to say the least. My heart goes out to each and every one of you dealing with this BS when you absolutely need the help the most....

    -Dougie
    Realize that FEAR is our worst enemy. Get up & get out in that stormy weather of the real world & kick fear in the teeth. Stare at it dead in the eyes & walk right through it into the storm; because once you're wet, you won’t fear the rain anymore
  • dkellyddkelly Posts: 4
    edited 02/03/2015 - 4:05 PM
    Found out today from my surgeon that is just a temporary fix to get me back up and running and to maybe get 3-5 years before a more permanent solution (fusion) would be in order. 4 more weeks of walk and rest and then several weeks of PT. With my work I have a 12 month window to get back on the street then medically retired if I cant. Problem is not of age to retire, no pension till you are. All from a medical denial........sigh........
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