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Update on Gwennie's denial~

gwennie17gwennie17 Posts: 2,912
edited 06/11/2012 - 8:42 AM in Back Surgery and Neck Surgery
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.

xx Gwennie



  • gwennie---I am so sorry you are going through this-it just %^&*(( me off when I think of someone sitting up in an office somewhere deciding our fate---I am praying for you-love,Jeannie
  • I wish you the best in your pursuit for getting your surgery approved. Insurance companies are so frustrating to deal with. You are a smart woman and I am sure you gave them a run for their money today. I only had Grade I spondylolisthesis, but it was my horrendous symptoms that swayed my NS to do my fusion. I can't imagine how I would be if my insurance company had denied my surgery just based on a number.

    Good Luck,

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  • So sorry you had to wait for two weeks just to get frustrated by Ins Co. I know how it feels. I too had the refusal from ins co based on not meeting qualifications. I went through all appeals and prevailed. It was all about going through the external review, and having an disinterested party tell them if the discogram was redone, with recorded pressures, I met qualifications.
    So swiftly go through Co appeals, and take it to the state ins comm for external review. They look at things differently than Ins Co do.
    Is that a good enough Rah Rah Go Get Em speech for you? I hope so, I want to give you all the hope I can. Take Care, Robin
  • I think the insurance companies put the bottom line before your health. No brainer there. However, that doesn't make it stink any less! It sure seems like the word of your two trained doctors (who actually laid eyes on you) might outweigh the decisions of a panel of actuaries. I wish you great strength in your fight. Sounds like you're gonna need it.

  • Damn sorry to hear that Gwen. Keep after them, I know you will prevail. You know wayyy to much about the spine and your condition. :))))

    I had a neurologist appointment for early April and got a call that the Neurologist cancelled my appointment saying he cannot help me and that I need to see a neurosurgeon or pain Mgmt Dr. :(

    Today must just be a bad news type of day.... Hang in there.

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  • Hang in there Gwennie! I am so sorry you have to go through this and I truly know how frustrating it is to have someone behind a desk determine your future!

    We are all here to support you! Sending prayers for strength, courage, and patience your way! Hang in there I know you can do this! Shari
  • hi gwennie
    so so sorry your going thru all of this..this is just horrible how can they deny request for surgery they are not medical experts..
    how sad you have to wait and go thru this stress
    i'm truely sorry..
    things have to be done with insurance co.
    mine will pay for pt for me to go get u/s massage treatments but will not approve a tens unit..
    they will pay up to 3,000 for pt a yr but wont ok a few hundred dollars.
    hope you get your apeal won quickly
    neck,bone spurs pain started 04, back issues and fusion l4,l5 06~hardware removed.
    good few yrs. 09 pain sharp, numbness feet,legs, diagnosed fibro, neurop. legs.lung issues.
    daily goal do good thing for someone.
  • Hey, not surprised. As others said, it's about making money and they are using actuaralists/statistcs whatever to make 'profit/loss' decisions.

    I am glad you are posting to make others aware of how to prepare. I will 2nd the "get a copy of your records". I've been asked 'why?' we have them on line. I tell them, thanks but I never know if I will move and/or if I get hurt the Ambulance won't take me to a hospital that has access to your records and I feel safest if I have a copy.

    Typically, you can sign a release to ask for a copy of
    - all your doctor appointments doctors notes
    - operative notes
    - release/discharge notes
    - radiology reports and images

    It's worth doing.

    I have to clean mine up but I have everything from my ER hospitalization back in August up to pre-op of 2nd surgery. I will be sure to get all my information on my recent surgery after I'm cleared for this very reason.

    It's a papertrail they hope you won't track.
    I treat my medical records like the IRS tax records.

    You will appeal and get through.
    If you have to contact your state rep, do so.
    The state doesn't want you on welfare or disability so if it comes down to it, they will fight to get you the surgery.

    I'm so sorry you are still battling but you are chipping away with each meeting and phone call.

    Stay tough!
  • Yeah, I have all of my notes/surgical reports/Mri's etc... I'm pretty meticulious about it. I have them in a binder and It's pretty full. That's sad isn't it?
  • Thanks, everyone, for your support. It means a lot.

    When my surgeon came into the exam room today, he was carrying a stack of papers about 1 1/2 inches thick...pointed to it and said it was all from trying to get insurance approval.

    His one comment was that he is getting really sick and tired of everyone practicing medicine without a licence and telling him what he can and cannot do. I'm afraid this is just the tip of the iceberg for all of us who are spoiled here in the US.

    On another note, I suggested to him that my nerve pain symptoms were changing and were somewhat different from the last several years, and perhaps I should get a new MRI. He wrote the orders, and I will be going in Monday. Hopefully it will show some new things....

    Oh, and one more thing regarding records...when I was talking to a nice, helpful person at my insurance company one day last week, I had sent one somewhat cryptic email to no one in particular, which I never got a reply to...but I found out that they had a copy of it in my file! The helpful guy told me we could do everything online and did I want to switch so that all my correspondence came online? I told him that I needed everything in writing because I wasn't sure that email correspondence would hold up in a court when I sued to get my surgery approved.

    Again, my point is that it's great to do things online, but sometimes it is important to have paper copies of correspondence, etc. You never know when you may need them!!

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