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Post fusion people...

AnonymousUserAAnonymousUser Posts: 49,322
edited 06/11/2012 - 8:27 AM in Back Surgery and Neck Surgery
Did you have spinal instability in order for your insurance to pay? Mine lists two criteria, spinal stenosis (I have) spinal instability or spondylolisthesis (no "gross" instability noted on films). If you don't have both, they say, they won't pay for fusion surgery. I have Blue Cross/Blue Shield and it is currently in Appeals. Just wondering if anyone else encountered this. Thanks.
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1

Comments

  • I didn't get any trouble from medicare when I was scheduled for my fusion. I had multiple problems going on like recurrent herniation, nerve impingement, severe DDD and retrolisthesis. I never liked Blue Cross because I heard they have a reputation for giving a hard time so I never enrolled with them. I hope you win your appeal and get the surgery you need.
  • I had them for my surgery. They denied ADR all the way up to NYS insurance level of appeals but approved the fusion in a matter of minutes. I heard you have to have at least 6 months of unsuccessful conservative treatment before they approve surgery. I had 6yrs and a discogram to prove it was the disc.

    Good luck with your appeal. Make sure you keep copies of everything you send to them and document everything too.
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  • I'm not sure about spinal instability, but I had grade 2-3 spondy with severe bilateral nerve compression at L5-S1. I didn't have any trouble with insurance; however, I spent many, many hours working through insurance issues when my son required five surgeries during his first year and a half. Your surgeon should be able to provide the insurance company with adequate information as this is their livelihood. If they believe you need surgery, then they can usually support the claim. Insurance companies like to make qualifying very difficult hoping that a small percentage of people accept their initial response.

    Hang in there and good luck.
  • They told me in a written document that spinal instability is one of their "requirements" in order to approve fusion. Cripes, they want your back stenosed, your spine instable before they will help you? It seems so ridiculous to me - in other words, get completely incapacitated. I am try to do this early before it gets so bad that there is no turning back. UGH! I am going to keep fighting for it, but just wondered if this was a common practice. My doctor's office said they have done all they will do, to be honest, they are not being real helpful and will only send what paperwork and office visits and exams they already have. I asked for them to dictate an additional letter and got a firm NO, stating again they have done all they feel they should have to do. I wonder how many people really know what the policy they sign up for will or will not pay for ya know? How in the heck would I know that those are their guidelines - they are not in my coverage book. I guess those "rules" are volumous so they can pretty much change it or make whatever rule they want without the consumer knowing as long as some doctor on their committee says it should be that way. Makes me think that with the economy the way it is, the insurance companies are looking for ways to cut back too and not paying as much as they used to. Just my opinion...
  • I had the same surgery but with the LT CAGE PROCEDURE WITH INFUSE. How are you doing.
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  • I'm doing pretty good, but the recovery process is slow. I was feeling pretty good at weeks and for the past two weeks, I've been fairly uncomfortable after sitting awhile or sleeping.

    When was your surgery and how are you doing?
  • My upcoming ALIF had to go to appeals with Mercy Health Plans before it finally got approved. I don't know the specific reasons for the holdup, but I do know that if I were having a PLIF instead of an ALIF, it would've gone through much more easily (though the nurse didn't say why...I assume it's because the ALIF requires 2 surgeons?). Anyway, I hope yours gets approved ASAP!!
  • I have work comp, so my situation is slightly different. What I understand about my personal insurance,tho, is that they want you to have 3 epidurals, flunk PT, try meds, and basically exhaust al conservative treatments. A positive discogram generally give them nothing to argue about. You just have to jump through the hoops fist. And honestly, even tho it is a pain in the butt(sometimes literally!) at least the patient knows that they tried everything before getting surgery which can lead to so many complications(I've had 5 in less than 2 years.)

    Good luck to you, I know fulfulling their requirements is the last thing you want to worry about, you just want to be better, but we do have to jump thru the hoops.
  • EMT Lady, have you tried all conservative measures? Injections, PT, meds? If not, that could be why the refusal. If you fail conservative treatment I would have thought the bone on bone DDD would get you somewhere. That is crazy that they just deny it. I have heard of others who had denials where their doctors were not wording the reports to the satisfaction of the insurance, or some of the reports were missing. Keep trying and don't give up. Peristance sometimes pays off. If your doctor won't keep advocating for you, get another doctor. Good-luck, Sue
  • I had 2 times of being refused. If you look at post I answered to person on here that had been denied by UH, I gave him all the specifics. I had to go through discograms 2 times. Do you have disc problems such as tears? Keep fighting and look at the other post. I went into great detail as to what I had to do. Also, your Dr should be your best advocate! Mine wrote a six page letter. I will give you his name. Hes the best! Good Luck and PM me if you want more info. Anything I can do to help anyone to not have to go through all the frustrations, I will be there for you!
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