OfflineGreetings to all. I am in need of your thoughts regarding a denial from my HMO for a second opinion with a NS. My 1st NS maintains that he is mystified as to what is causing my left arm pain,weakness,muscle atrophy and absent tricep reflexes.My MRI and Ct reports reveal a central herniated disc with spinal cord compression,multiple osteophytes impinging on the foramin and EMG show severe c7 active denervation. Because of the NS inability to see a problem, I requested a 2nd opinion with a NS but was denied!!!!! They want me to see their ortho Dr.,yet I hesitate because upon investigation I have heard this Dr does not have favorable outcomes. It seem he takes on cases that my NS won't touch!
I paid for an independent opinion outside this medical group at a leading University hospital This ortho spine Dr was not mystified and was very concerned at the level of arm weakness I had and felt surgery was indicated ASAP. So actually I wanted a 3rd opinion and was denied!!! The 1st and 2nd are so different and that what leads to my hesitation to commit to surgery.
So my question is do I appeal this decision with the medical group and insurance company? Should I see this ortho DR they want me to see? My husband wants to again PAY out of our pockets for the 3rd opinion.The good news is that effective Dec 1st we will be out of the HMO and with a PPO and i can go where ever I want!!!! I am really afraid to wait because the symptoms are worsening and the Ortho Dr said the longer I wait ,the less chance of neurological recovery I have.At the rate these Drs are taking, it will be 2009 anyway. I am so tired of all of this run around. I cried so hard on Friday because I can't see an end to this. Your thoughts or ideas to clear my mind would be helpful. Thanks, Bethy
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Hi Bethy,
I would keep trying to get approval to see another NS. I actually saw two NS and one othopedic before scheduling the surgery I had on Sept 17th. My insurance paid for both NS but the Otho surgeon was out of network and my insurance would only pay 70% of the amount that would have paid someone approved and this 70% was after a $200 deductable for going out of network. The doctor was great however and he took $250 off the bill (which was $575 I think). I like having multiple opinions but in my case they were all the same and in agreement that I needed surgery ACDF. The only differences were how many levels (two said 4 levels, the one I used decided on 3), and what type of graft, hardware, spacer etc was used. The original NS I was going to use but he ended up taking an emergancy medical leave himself and he referred me to the second NS who did the surgery. You can say you want additional opinions because the doctors you saw were not in agreement but you might have to see the doctor that your insurance recommends. That does not mean you have to let him be the one to operate.
LJ
9-17-08 ACDF surgery with titanium plates and screws. C3>C6. C6/7 left out of surgery and has damage but NS hopeful this will not cause problems. Strategic choice to do a 3 level rather then a 4 level fusion. Major arthritis in spine as well as DDD. Using Bone stimulator to improve fusion rate. 30+ years of back pain but the neck pushed me over the edge.
I wrote up an appeal and faxed it in at 830 am. I was Approved by 1100am!!!
I was up all night writing it and I made a good case. I will now be seeing a top NS in Chicago next week.To think I was ready to throw in the towel.
Bethy
I'm so glad you got that approval!
With those two doctors having VERY differing opinions as to what's going on you I wouldn't have thought you would have had such a hard time. Please keep us up to date with what they find out.
Great, I think you did the right thing, it is YOUR health and you must be your own advocate. What isurance comapanys are getting away with is crazy, good luck at next app in finding the correct answers and hopefully a course of action to relieve your pain,
Do keep us posted
Eve
May 9th. 2008 2 level acdf, C5-6 and C6-7, myelopathy, stenosis.
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Eve