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Update on Gwennie's denial~



  • I am sorry to hear about your battle over approval. Of anyone though, I believe you will find a solution and be able to move forward. Your tenacity and strength will get you where you need to be. Surely if your surgeon is confident that the fusion is in your best interest then the insurance company will too. I hope it is just a matter of getting the right data in front of the insurance company. Stay strong.
  • I'm sorry to hear that you are still having a problem with your back. I don't know if you remember me.... I had the microdiscectomy 2 times on L5-S1 last year that left me with permanent nerve damage. I am doing the trial Implanted nerve stimulator now ( it will be taken out tomorrow) It has been wonderful!!!! I have Humana Insurance and we had to fight with them to approve the trial unit and now will have another round to get the final one placed. Has the stimulator been an option for you at all?

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  • Gwennie, I so sorry to hear what you are going through with the insurance. I WISH our legislators would get a clue. An actuary as defined in the dictionary: ac·tu·ary
    1.Insurance. a person who computes premium rates, dividends, risks, etc., according to probabilities based on statistical records.
    2.(formerly) a registrar or clerk.

    And to top it off becoming an actuary is the #11 top college degree. So insurance companies pay more in those peoples salaries than it does for most patients care.

    How dare a clerk decide what care you require!! I am always astounded by what some insurance companies do to their insured. I wish you all the luck in the world dealing with supposed requirements. Funny they cannot describe their requirements.

    You gave great advice on medical records. Keep them people. I too have a binder.

    Keep after them!!!
  • dilaurodilauro ConnecticutPosts: 13,531
    always as being the 'black knight' as being described here.
    Sure, there are problems with our Health system, here in the USA as well as other countries Health systems.

    Insurance. Just take a step back about 15 or 20 years. Insurance premiums were a lot less and the idea of pre-certification and reviews really did not exist.

    Some of the reasons that began to change was because of the increasing number of law suits initiated by patients against their doctors and/or hospitals.

    Now here we are today and the rules are stricker and approvals become tougher.

    The way to ensure you get the appropriate treatment

    - Keep accurate records
    - Maintain CD's for all of your MRI's and X-Rays
    - Request medical records for all of your major visits.
    - When using online methods, make sure you include delivery and read receipts for all correspondence.

    Insurance companies are not the enemy. They are just operating under guidelines imposed by the laws of the Health systems.

    I have heard repeatedly for those in the medical field that so many 'denied' requests would never happen if the patient did all of their homework from the beginning.

    I am sure each situation is different and I can not say if one case vs another is right or wrong. But today, the emphasis on making sure you get approvals rest on us, the patient.

    Ron DiLauro Veritas-Health Forums Manager
    I am not a medical professional. I comment on personal experiences 
  • Sorry to hear that you are still having troubles, I was kinda hoping it was some "clerical" error.
    Know that you are in my thoughts every day. You are always there for the rest of us, now it's our turn.
    Lean on your Spiney friends whenever you need to, were right here for you.
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  • What I think I am seeing is a general crack down on unnecessary back surgeries. The increase in spinal surgeries has been quite astounding in the US in the last ten years, statistically speaking. I think with all the focus on healthcare lately, insurance companies are re-examining their criteria for various surgeries. I have noticed that more and more companies are using this Milliman care guide which has very specific criteria for surgery.

    And, anecdotally, surgeons are reporting more initial denials.

    I'm not quite sure how I can meet these guidelines as one criteria is neurological claudication...but they won't accept an EMG test result as proof! I guess that's what the appeal is for -- when you fall outside the specific criteria.

    All I know is I am spending a great deal of my life on the phone with various people connected to the insurance process!!
  • I am facing the same insurance nightmare. I was supposed to have discogram on Friday. The last time I had fusion, they wouldnt accept a non weighted one. So I had to go through appeal on it. Then after I went through the state appeal, that Dr said if I had a weighted discogram, I would definitely need fusion. So I had the weighted one.
    Now, we are going for the weighted one, to avoid the appeal from that, in Mpls, as there is no one in Iowa that does them. Now insurance company is giving the run around about it being out of network. Which has a 10,000 ded. But since no one does them in Iowa, Not even U of I, I have to go to Mpls. And they have to pay in network, as there is no one in Iowa. Geezzz , I cnat figure out which way they want it. They set the precedence with the last go around. And I have the documentation to prove it. ARG
    It is so frustrating! Good Luck wih yours, hang in there. Im thinking of you. Take care, Robin
  • Read your comment about the amount of back surgeries....It's so true. Here in Reno one of my Dr.s told me that more back surgeries are performed here than any other procedure, so it's no wonder that the insurance companies are making us crazy.

    Hope it all works out for you.

    BTW, my Dr. won't accept Medicare anymore and I have to pay him out of pocket and hopefully get reimbursed from my tertiary ins. carrier. I've had this happen before and my poor husband gets stuck with all the paper work. Sometimes it takes months to get it resolved sometimes even longer.
  • with the insurance company!

    I am so sorry you are still dealing with all this and i do pray you will prevail and get your surgery in the end.

    I too am fighting with my insurance company over a different test but its got me going around in circles and getting me no where. No point in getting into the details but I can understand your frustration, as insurance companies just don't seem to budge!!

    Hang in there, stay strong, and keep fighting!!!!!

    Good luck with your MRI,
  • I too was denied a fusion by Aetna. Their reason was that "Spinal Fusion is considered experimental as treatment for DDD" Within 48 hours of denial my surgeon did a peer to peer telephonic meeting with Aetna's surgeon and explained why I need this fusion (treatment for failed ADR, this is our last chance to fix this level) and was able to get it approved.
    Last year I had Cigna and had no problem at all getting an ADR approved the first time. I don't understand that at all as ADR is still relatively new in the US.
    I really despise the fact that it is up to these insurance companies to decide whether a specific treatment will work for us or not.
    Don't give up Gwennie, keep fighting and make them cover this for you. They have to understand that each case is different and they have to treat them as such.
    I am wishing you the very best in your fight with the insurance company, don't give up...fight the good fight!!
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