After waiting two weeks to speak to my surgeon about the reasons why my multi-level fusion was denied, I went to see him today. We had a 45 minute conversation and I left feeling much better about the situation.
Then I came home and got on the phone with my insurance company. Things went downhill from there! I'll spare you all the details but what some of you may be interested in is that a number of insurance companies are becoming more finicky about authorizing fusions. They are using what is known as the Milliman Care Guidelines, which basically state that in order to qualify for fusion there are several conditions that must be established.
I won't quote the standards but the reason I was denied is because I didn't have a spondylolisthesis that was great enough to suit them and they did not feel I had demonstrated proof of neural claudication. When I told the woman I had two EMGs from different neurologists that stated I had chronic radiculopathy at S1, she told me they didn't pay much heed to EMGs because they were "subject to interpretation." I told her so were MRIs...that they do not always reveal what is wrong with the spine, and it was up to what the radiologist chose to emphasize about the MRI. She tried to tell me they could only make an evaluation on the information that had been supplied....We went back and forth for awhile, mainly over procedural things, and all in all, it was an upsetting conversation. I was left with the impression that it is not enough to meet the standard's criteria; you also have to prove it in a way that they find acceptable...but, so far we haven't had any luck finding out exactly what makes up their criteria.
My insurance policy says surgery is covered. It doesn't go into detail about how it has to meet particular criteria that are established by a team of actuaries and that this has precedence over several experienced surgeons who actually examined me!!
In addition to denying the fusion, they would not allow a decompression surgery instead, for similar reasons. I was basically told "you do not meet our criteria." We went round and round over what that meant, as it turns out, so has the woman in my surgeon's office. She hasn't gotten anywhere either!
I know Humana, Aetna and Cigna, among other large companies are all now using this criteria. I mention this so that if any of you have insurance through one of these companies,you will know to do what you can to clearly establish the reasons why the surgery is necessary.
I still have two appeals. I have not begun the first one yet because it has taken two weeks to find out WHY I was denied in the first place. I feel reasonably confidant that I will prevail. If not, my instability is bound to get worse.... @)
I've never had a bit of trouble getting anything covered previously. I thought maybe it was because we were requesting a 3-level fusion, but that is not the case. They refused fusion and they refused laminectomy.
My surgeon said he is noticing an up-tick in denials. Since mine two weeks ago, he has had two additional. I wonder if this is a harbinger of things to come?
I urge you all to keep copies from every appointment, get records from every imaging test you have done, any treatments, etc. Keep a paper trail if you think you might ever need surgery. Get copies of all MRIs -- it is easiest to request a copy at the time of service.
So, this completes this episode of my on-going soap opera. Stay tuned for the next spellbinding installment.