Insurance denied!!!!

Insurance denied!!!!

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bigmamaree
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Joined: 11/28/2012 - 2:16pm
Insurance denied!!!!

**I posted this in January Surgery Buddies, but I'm looking for any support possible!!! I received a call yesterday from the insurance company that my surgery wasn't approved. I'm devastated! It's one of those things where the doctors notes need to state specific wording in order for it to be approved. From all the past procedures I've had done, it is clear that surgery is next but I guess they are looking for specific verbiage such as spondylitis (sp?) or arthritis, ect. I was very upset because of course they call me at 4:30 on a Friday evening of a holiday weekend, and there is nothing that I can do now until Wednesday which is the day if my pre-op. The insurance company (or I should say the rep that called me) is so stupid cause I asked her if I should still go to my pre-op while this is being disputed and she couldn't give me an answer! So now what?! When I was going through my records, it appears that the info they are looking for is stated and relevant. My thoughts are: the dr told me 4 years ago that I would need this surgery. I chose to try PT, PM, injections, blocks, etc. so the doctor should be able to turn this around in time for my surgery date. Has anyone had similar issues with their insurance? Should I really worry? I'm just more so pissed that they call when there is nothing that can be done about it and I'm left all weekend and Christmas no less worried about this. Please help me make some sense of this!!!

tran92
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been through it myself

my surgery was denied. doc was told to speak to one of the insurance docs for a peer to peer review. he tried multiple times and the doc in question would never get on the phone with him. (and the other docs he spoke to said they wouldn't make the decision for this guy.) meanwhile insurance was willing to do a laminectomy, based on the 1 paragraph report they read from an MRI. but they wouldn't do the fusion. meanwhile they had already paid for 2 previous microdisecomties with hemi-laiminectomies. why would they think a 3rd was going to work?

anyway, doc wasn't getting anywhere. they cancelled my pre-surgical testing. and while this was happening, we wrote a coplaint letter and managed to send it to 7 corporate execs. one of them read it on a wednesday night. thursday afternoon the insurance company called me to say they would approve my surgery. i got the pre-op testing scheduled for the next morning (friday) and had my surgery monday morning. i got the approval 5 days before my scheduled surgery date, and was lucky they hadn't given away the OR time slot. since they had already cancelled my surgery.

but technically, approval came from corporate, not the docs, so my surgery is still classified as "not medically necessary."

my doc was shocked when i got the approval. he never expected them to do it, figured we'd have to appeal and maybe i'd be able to reschedule in about 6 months if i was lucky. the insurance companies don't care what your doc thinks, or what the films look like, they base their decision on minimal info, and how much money its going to cost.

it really sucks.

Microdisectomy / hemi-laminectomy 6/2010 and revision 10/2010
Cervical fusion C4-5 and C5-6 9/2011
Lumbar Fusion L5-S1 6/2012

driven.like.the.snow
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Bigmama

I replied over at our January buddies, but I want you to know I'm here for you! My original hybrid surgery got denied as well. And the kicker was, my scheduler KNEW they were going to deny it, and they made him submit it anyway! Talk about wasting time.

Try to relax and enjoy the holidays, and know God will work everything out. If your office is open Monday, definitely let them know you want to keep the set date, and see if they can work something out with your insurance. Most of the time they want it worded in an exact way. If you've done all the other options leading up to surgery, your insurance should approve it. Perhaps a conference call with you, insurance, and your surgeon may help? I actually opted for the 2 level ALIF instead of battling with insurance because I need this surgery done. I'm a single mommy of a 4 year old boy, and I want my/our life back.

Keep your head up, sweetie. It will work out. Smile

DDD L4-5 & L5-S1 w/ herniation
Failed discectomy, 8-15-11
Discogram, 11-14-12
L4-S1 ALIF (2 plastic cages, 2 plates and 8 screws), 1-4-13
FBSS & SI joint dysfunction, 12-30-13
1 year post-op CT hardware scan & left SI joint injection, 1-17-14

bigmamaree
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Thank you!

I truly appreciate your responses to my post. A part of me feels like this will get worked out, I just need to remain patient. The other part is just getting worked up thinking that I was almost at the finish line an tripped and lost! I will take your advise and sit tight until Monday. I'm not sure if they are opens or not, but their answering service believes that they are half day. I'll keep you informed on how things go from there. Enjoy the rest if your weekend!!

Bigmamaree
Lumbar DDD
TLIF 1/2/13

Davey16
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MIne was denied

Mine was denied after I had the surgery,by Workmans comp, 4 months after the fact and because I had everything related to my claim they have finally approved it. Keep at them they are paid to deny you.

jellyhall
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Joined: 10/16/2009 - 5:38am
Bigmamaree ...

You haven't lost yet!
Don't give up hope Smile

bigmamaree
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Christmas Eve Update

So of course I reached my fear that everything would be closed today. Not able to reach the doctor or surgical nurse. I tried to contact the hospital for the pre-op dept but they too were closed. Last hope was to contact the insurance company who said again that it was my choice..... BUT if the surgery is denied, then they won't pay for the pre-testing. So I guess I won't go Wednesday . I feel bad because I can't call to cancel. (My appt is at 8am) I'm praying that we can get this overturned quickly. Everyone has changed their schedules around me. My mom was even coming up from Georgia (I live in New York) to help me. Please keep me in prayer!!!! Other than this, everyone have a great Christmas and love the ones you're with!!!! Thanks for your support!!!!

Bigmamaree
Lumbar DDD
TLIF 1/2/13

driven.like.the.snow
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bigmamaree

I'm sorry, darlin'. I know some of my offices were open Monday, so I was hoping yours were too. (I'm right below you in NJ.) Did you go to your appointment this morning? I was thinking of ya! Please let us know how you're doing and if you were able to get things worked out. Maybe your surgeon can put a call in to your insurance and push it through.

Hope you had a good holiday!

DDD L4-5 & L5-S1 w/ herniation
Failed discectomy, 8-15-11
Discogram, 11-14-12
L4-S1 ALIF (2 plastic cages, 2 plates and 8 screws), 1-4-13
FBSS & SI joint dysfunction, 12-30-13
1 year post-op CT hardware scan & left SI joint injection, 1-17-14

davrunner
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Joined: 02/18/2011 - 8:11am
Had a knee replacement denied

I was on my way to the hospital for pre-op when the surgeons assistant called and said the insurance had denied the op. I had already had 4 other surgeries on the knee, underwent synvisc treatment, had been taking rhuematoid arthritis meds for 2 years and they said it was denied as I hadn't attacked the RA agressively. I didn't do the pre-op that day. The OS called the insurance and did the Peer to Peer and I got a notice 3 days later that it was approved.
Hang in there, hopefully your surgeon can help...

laminectomy c4/c5 2008, ACDF c4-c7 Jan 20 2014 sched

bigmamaree
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I've finally been approved!!!

Thank you all for your support!!! I was finally able to speak with the surgical nurse who was able to explain to me what the insurances issues were all about. She said that the doctor was upset that they declined but not to worry cause after the peer to peer things will be fine. And she was correct! I was very happy that I didn't need to appeal. And even though I didn't go to the 8am pre op, the hospital was nice enough to squeeze me back in at noon. I'm on my way again!!! Back to being anxious and nervous.... But it's worth it!!!!

Bigmamaree
Lumbar DDD
TLIF 1/2/13

Sally711
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Joined: 08/31/2011 - 2:13pm
Yay!

So glad to read your last post!!! Wishing you all the best!!!!!!

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