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Are Medical Policies Killing Us/Me?

nutcase007nnutcase007 United StatesPosts: 130
edited 04/05/2016 - 5:07 AM in Back Surgery and Neck Surgery

 I have a neck condition given to me where I had my neck broken because of being rear ended in a car accident.  I have already have two fusions in my neck over the last ten years.  I never recovered from my last fusion.  I have severe pain in my neck, shoulders and upper back.  I addition, I have significant loss of motor function in my one arm.  I have had multiple MRIs, bone scans and x-rays.  All the tests keep coming back with "Can't find any significant problem, nothing to be done".  I've lost my job, cannot work and have been denied LTD disability.  The accident happen many years ago, so the statutes of limitations ran out before I started having neck problems.

My last neck fusion was two years ago.  The surgeon made the comment after surgery that he didn't understand how I still had any motor function left in my arms or legs.  Recovery went well for six months and then turned bad.  At twelve months, things got so bad that I had another round of tests (MRI, bone scan and x-rays) and went on short term disability.  From the bone scan, the broken facet joint at the level that had been fused twelve months earlier was still very inflamed, so a nerve oblation (RFA) was performed.  I was able to get back to work for a few months, but my neck continued to deteriorate.  I could no longer continue work and was fired from my job.  

The last two paragraphs are all background to my up coming question.  Recently, I was back in my surgeon's office showing him my increasing loss of motor function in my arm.  He ordered a Cervical Discogram which was denied by the insurance authorization request, because the insurance companies "determine cervical discograms to be experimental".  That is being fought on appeal for medical necessity.  They will gladly do the cervical discogram, if I pay for it (if I only had the money).  On the internet, I found one of the insurance companies policies published for discograms and they state only to be performed when, I quote "unremitting pain with significant functional impairment of at least twelve months duration".  I asked the insurance company how these policies are determined and they claim they are developed based upon guidelines from the medical professional boards (aka AMA, etc). 

Here is my question, are doctors hands being tied by "guidelines / medical policies"?  This goes beyond what an insurance company determines what they will pay.  To me, it smells like this doctor could have been accused of bad medicine if he had not followed medical guidelines and would have ordered a discogram a year ago.  I am being told that this cervical discogram is the only remaining test that might identify the cause my neck issues.  It is documented that some disc issues are known to NOT show up on MRIs, bone scans and x-rays.  So it smells to me that I have been forced to suffer for an additional twelve months and lose my job because of medical policy!     



  • itsautonomicitsautonomic LouisianaPosts: 1,807
    edited 04/05/2016 - 11:52 AM
    Yes and no.  In many cases they do , in others it is simply the justification the dr writes up and how detailed .  Cervical discogram is not experimental , but the results of a discogram can be controversial because they are sticking a needle in your disc and pressuring up so some believe it would cause pain no matter if good or bad disc. I had to go out of town for my thoracic discogram because they Drs in my town had never done one.  It will also speed up degeneration and also cervical discogram , as dr told me, has more risk.  Now for me and my dr discogram was the best thing I ever did in thoracic it revealed annular tear leaking fluid and there was no confusion.  It led to a treatment plan that helped me avoid surgury and ruled out a herniation as my main pain generator.  

    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.
  • nutcase007nnutcase007 United StatesPosts: 130

    Thanks itsautonomic for sharing your experience.  Its good to hear a success story. 

    On the "experimental" part, the insurance company claimed that experimental means in insurance legalese that general excepted medical policy does not approve this procedure except on individual documented medical necessity cases.  I think I'm almost saying the same thing you wrote.

    If you want to make your head spin, Google "cervical discogram experimental" and read some of the posted policies.   

  • dilaurodilauro ConnecticutPosts: 9,856
    Cant say for all cases, but I do know first hand that the doctor's hands are being tied and they are being forced by the insurance companies on what can be done.  Medicare then throws a bigger problem into the barrel making it so more difficult for doctors.

    I would not want to be a doctor today who needed to code and justify a condition or treatment for a patient. It is so difficult,

    To me what can be the bigger problem is above the insurance companies.  Why do we have insurance?  To cover situations when people are being sued!   Today, who starts most of those situations and who benefits the most!  Think about 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
  • gfishggfish Pittsburgh PAPosts: 159
    My experience would be that my insurance wont let my doctors go in to have a look around with an MRI or Ct scan. Only if truly needed. Any medical procedure would have to show warrant. Not, we could try this and see if it works. Im kind of like you in the same boat. I had a major fusion. Didnt  end up so well.  Actually worse. My Insurance is spending money on me for PT, Pain management doctors and other stuff for over a year now.  But hold back on the real money. I think they look at us like a risk. That we might never get any better so why pour money into someone that will always be like this. 
    Greg fisher
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