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Hey Everyone, I am hoping that I can find some help here and get advice because I am lost.
I am 48 years old and have been battling back trouble for going on five years now. I have severe DDD, and have exhausted all conservative options that could have helped my problem. I am in severe pain at all times and am not a great candidate for pain meds, being that they make me ill. I was told by two Orthopedic surgeons that I need a lower lumbar spinal fusion. I have been denied stating not medically necessary. My doctor did a Peer to Peer and was denied also. I just completed my first level appeal and they are still stating that this is not medically necessary because my spine is not "Instable". Yet my doctors tell me that within a years time, I could be unable to walk and be forced to go on disability. I have grandkids and also a life to live. I just want my back fixed. Can anyone respond and let me know how I can maybe get this overturned????? I am in desperate need

P.S. I have Anthem Blue Cross


  • I have never ran into insurance issues with my back. Good luck, I hope you can get them resolved soon.
    33yo mom of two. My surgical history...preadolescence scoliosis, kyphosis, and a hot mess.... 5 spine surgeries and lots of items added I wasn't born with (titanium, peek, surgical steel). Guess cremation is out. TSA loves me.
  • it seems to be the way the insurance companies are going these days. they're claming that there isn't enough hard data to prove that a spinal fusion will actually help in alot of cases, so they are blanket denying them. I think its especially true when the sole diagnosis is DDD.

    i also was told i needed a lumbar fusion. I had 2 laminectomies prior. i had my surgery date, and insurance denied it saying not medically necessary. my doc also tried the peer to peer, and couldn't even get to talk to the doc listed in the letter. they would put him through to different docs, and each one would say they couldn't override the 1st doc's decision or they weren't qualified to make a decision. it was a total run around. my doc had told me at the time, that there were cracking down on the approvals, and we would have to go the appeals route, since we weren't getting anywhere with the peer to peer.

    (meanwhile i had a bone spur, that in order to remove it they had to remove a piece of bone that would have made the spine unstable, which is why i needed the fusion.)

    but the insurance company looked at the 1 paragraph report from the MRI and ignored the CT scan reports, and wouldn't listen to the doc, or look at the actual images showing this bone spur pressing into a nerve root.

    we ended up complaining to corporate. email and letter to 7 of the top execs. well, one of them read it on a wednesday night. thursday afternoon i get a call from the insurance company saying they will approve my surgery and they are going to call my doc's office after they speak to me, to let him know as well. the woman who called told my doc's office, she couldn't figure out how i got the approval since it didn't come from their own doctor's office. it came from corporate.

    my doc was shocked to say the least. but thankfully that was thursday, and they hadn't given away my OR slot for monday. and i was able to keep my schedule for surgery, but it was a nightmare for weeks. and while they did pay for the surgery, they would still say its not medically necessary.

    oh but they were willing to do a laminectomy for me. they kind of ignored the fact they had already paid for my 1st two. but we stressed that fact, and how they weren't listening to anything my doc said, or the other opinions i had, or looking at the actual MRI and CT scan so they weren't making an informed decision. something in the 3 page complaint we wrote got their attention.

    can't say it will work for you. but that's what we ended up doing to get my surgery approved.
    Microdisectomy / hemi-laminectomy 6/2010 and revision 10/2010
    Cervical fusion C4-5 and C5-6 9/2011
    Lumbar Fusion L5-S1 6/2012
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