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IraqI Vetran denide Lumbar Fusion surgery

edited 04/09/2015 - 7:56 PM in Health Insurance Issues
I'm 46 years old male I served my country for over 17 years in the Navy and I served my home state as a Texas State trooper for 6 years. Since I finished serving my country since March 2011 my condition of my back have deteriorated to the point I'm afraid of leaving my house for fear of falling due to severe pain in my back, legs and so on. My doctor told me to try physical therapy, Lumbar injections (2). I am over a year into my pain management with no relief. I was just informed that my first appeal was denied for a Lumbar Fusion surgery. My knowledge is not up to par on this matter and I would appreciate any advice on what to do next. I just want some relief .
Barron W. Camp


  • LizLiz Posts: 7,832
    Please take the time to read this post and refer to it when you have questions

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    Liz, Spine-health Moderator

    Spinal stenosis since 1995
    Lumber decompression surgery S1 L5-L3[1996]
    Cervical stenosis, so far avoided surgery
  • SavageSavage United StatesPosts: 5,427
    And thanks for serving!
    I totally relate to your fear of falling. Although we may have different spinal issues..we share the fear of falling.

    I was falling.. and initially it happened unexpectently..no warning...just one second I'm upright and then I am laying on my back.
    Using a cane has helped me so much..with balance and with the pain of walking. But...I can and do still fall on occasion eve with the cane...so yes my getting out of the house is limited also.

    It's great you are with pain management! I've been under PM care about 7 years now. Realizing all spinal issues and treatments are individualized.....I felt more under control almost immediately, but for finding right combo of pain med and breakthrough pain med..took awhile for me.

    I am not a candidate for surgery. But it saddens me greatly to hear you were denied your needed surgery, esp. as you are a veteran, I would like to think your insurance would be backing up your doctor.

    Sorry I have no advice for you, but hopefully someone will come around who has similar experience which may help you.
    Hopefully some of the info referred to by Liz, above, will be helpful.
    Please keep us posted on how you are doing and any guidance you can get form your doctor.
    Best of luck
    Spine-Health Moderator
    Please read my medical history at: Medical History

  • Did you have any treatment for your back or did you identify back pain while you were with the military? If so, it may open more doors for treatment.

    Are you going through the military or other insurance for the procedure? Where I'm going with this is that if you got hurt initially with the military, you may options for them to pay for it. I'm not sure how Tricare works now, but when I retired in 2005, the military was responsible for further treatment especially if you were hurt while deployed.

    With private insurance, if you need a spinal fusion, it should be submitted by the surgeon doing the procedure. It's not uncommon to be denied the first time. The surgeon's office should re-file and add additional information.

    Several Epidurals, L4-S1 360 ALIF, Numerous Facet Joint Injections, RFA x2
  • I'm a certified medical biller and coder, can I have some things clarified ? Are you going through the VA? If so, I would immediately request to be seen by non-VA doctor ASAP. If the injury occurred in the line of duty or if you have a disability rating related, the VA has to pay.
    If it's private health insurance, call and file a member appeal. They tend to look at those more than a provider appeal.
    Hope that helps! Thank you for your service.
    Cauda Equina post MVA
    T-12/L-1 fusion, Thanksgiving 2014

    To get migraine medication I had to appeal three times. This is not uncommon for some insurance carriers. The other option is to contact the Texas Insurance Department.

    C4-C5 ACDF surgery with plating August 28.
    cord compression due to disc-osteophyte complex
  • jlrfryejjlrfrye ohioPosts: 1,110
    The Dr uses incorrect diagnosis or coding of the procedure. Make sure all previous treatments are included with the prior auth. Most surgeries will not be paid until certain requirements are met such as injections and PT. This could be a oversight on the Dr's part. Call your insurance company and find out why the denial. That way you will have a idea where to start with the appeal
  • big man, I appreciate you. All those years of looking out for us, wow..I really don't have the words, but thanks you.

    Appeal! I'm so sorry this has happened to you, especially the pain and the wait. I have no help to offer and hope some of the other suggestions help you to get to healing. My dad had a similar experience. He appealed. It was the coding and the infejections. They did an injection, resubmitted and he was cleared to have the surgery. That was 15 years ago, he is doing great. Best wishes for recovery!
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