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Anyone have DDD fusion surgery paid for by Blue Cross Blue Shield?

Well, as the subject says, does anyone have any success stories to share with having your insurance company pay for lumbar fusion surgery for DDD? I've read some stories about long appeals taking two years plus. Anyone have an easier path to this? Does a surgeon have much leeway in influencing the insurance outcome?

Thanks in advance!
3/11/13 successful ACDF
7/13 inconclusive discogram
Currently in PT for lumbar pain
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Comments

  • I work in a hospital business office( lots of insurance experince)and I had surgery last month. I have BCBS and they approved my surgery within a couple of days, no appeals done. But I had spondylitis, inflammation in my bones, pars fracture etc. basically my spine was unstable.
    If you have any stenosis, compression of your nerves, I think they will approve it for that. I had a 2 level L4/L5/S1 360 fusion( from the front- ALIF and the back PLIF.
    I would ask the doctor next time you go and let them know your concerns!
    99/00 L4/5 & L5/S1 herniation
    2001 L5/S1 microdisectomy age 25
    severe DDD at surgery level
    2011 pars
    2012 RFA L/3/4/5
    7-02-13 L4/5 l5/S1 360 fusion ALIF PLIF
    DX spondylitis , DDD, scoliosis, and slight kyphosis
  • Thanks for your input! I looked online at my BCBS coverage and they seem to be very strict on what is allowed and what isn't. Some of the procedures I have read about here (microdiscetomy for one) are not covered for any reason as they are considered experimental. There are very strict policies regarding lumbar fusion. My doctor is the one who mentioned that BCBS can be "tricky" about approving fusions. He had me have a discogram a few days ago (don't even ask-I'm still recovering) which I guess will show nerve compression.

    It was odd reading the BCBS policy standards. I had ACDF surgery in March and according to what I read that should not have been covered. Who knows though. I'm starting to realize that there is A LOT that goes on behind the scenes at doctor's offices that patients (at least me) have no idea about.

    I read through your list of surgeries- are you feeling better? My heart and prayers go to you.
    3/11/13 successful ACDF
    7/13 inconclusive discogram
    Currently in PT for lumbar pain
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  • I had plif L5/S1 on 6/12. First denied by BCBS, then approved after peer to peer consult. They wanted to be sure I had exhausted all options first. PT, injections ect. I had severe DDD and S1 nerve root compression. The surgery was a complete success! I was told 50 - 60% success rate. My back feels so much better! Good luck!! BTW they also approved my 2 level ACDF 5 weeks later.
    Chris
    PLIF L5/S1 fusion 6/12/13
    ACDF 5-7 7/17/13
    44 year old Mom of 10 and 12 year old girls, full time veterinary technician.
  • I feel better, about 85-90%. I start therapy soon and hope to be 99-100%.
    So there are bcbs Texas, Oklahoma, and Illinois that are kinda "shared".
    If you having something different then the policy can be very different. They don't want to pay for just DDD. But my dr listed that as my primary diagnosis. They will pay for it if your spine is unstable. I think there are 3 conditions they'll pay. Did your doctor say you only had DDD and nothing else wrong?

    The discogram will tell them what is going on with your disks. Mine showed tears and they grade them, I had some level 5's which is the worst. Did you have a CT afterward? My ct showed a scoliosis curve that the mri didn't.
    Have you gotten the report from the dr?
    99/00 L4/5 & L5/S1 herniation
    2001 L5/S1 microdisectomy age 25
    severe DDD at surgery level
    2011 pars
    2012 RFA L/3/4/5
    7-02-13 L4/5 l5/S1 360 fusion ALIF PLIF
    DX spondylitis , DDD, scoliosis, and slight kyphosis
  • I got approved right away for Alif L4L5S1 FRONT AND BACK.
    Kathy B
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  • They usually will approve right away if you have any instability! If you don't they generally require more tests to make sure that is the problem of your pain such as a discogram. Hope this helps.
    L5-S1 anterior/posterior 360 fusion Aug 2013
    Grade 2 spondy, Severe DDD L5-S1
    L4 Facet arthritis
  • Hi all-
    I had a discogeam and CT scan on 8/15 and will probably have an appointment with surgeon to go ob er results this week. The discogram was sickenly painful. Apparently the doctor haf s reslly hard time getting the needles in two of the disc spaces. The pain was the worst I have ever experienced and frankly I didnt know the body was capable of producing this level of pain.

    My surgeon is kind of vague about assigning a specific diagnosis. I have read over MRI reports to determine what's wrong: ddd at several levels and facet problems, from what I recall.

    Since the discopain was so excruciating, does this show nerve impigement? As far as stenosis goes, the reports all say no significant stenosis.k

    I am in NC and NCBS says they will only pay for cancer, spinal tuberculosis, and severe instability. I'm not sure if I even want surgery but it's nice to know insurance will pick it up if I need it.

    Do discograms "verify" conditions to indurance companies?

    Thanks everyone! !
    3/11/13 successful ACDF
    7/13 inconclusive discogram
    Currently in PT for lumbar pain
  • BentechBBentech Posts: 65
    edited 08/18/2013 - 7:13 PM
    Were you sent for a CT right after the discogram, they pressurize your disc and inject a dye if you have severe pain durning the discogram they should send you strait away to CT to have a look at the tear! The idea of the discogram is to duplicate your normal pain so they know what to fix.
    L5-S1 anterior/posterior 360 fusion Aug 2013
    Grade 2 spondy, Severe DDD L5-S1
    L4 Facet arthritis
  • inchwormiinchworm Posts: 695
    edited 08/19/2013 - 12:26 PM
    Like others who have commented, I was approved for fusion by BCBS but my diagnosis was more complex than simply DDD--radiculopathy, scoliosis...

    In my experience, the wisest thing to do is get pre-approval for any surgical procedure. If you have any questions, call BCBS and ask them what to do to get approved. In my case, my surgeon had to submit his surgical plan. With the changes in insurance coverage taking place, you can't be too careful when it comes to assuring coverage. Of course, everyone will likely have different coverage with their individual BCBS plan.
    Linda

    2009 Foraminotomy C6-72010 PLIF L4-S1Multi RFA's, cervical inj, lumbar injLaminectomy L3-4 and fusion w/internal fixation T10-L4 July 17Fusion C2-C5 yet to be scheduled
  • I had BCBS of Tennessee when I had my fusions last year. Took less than a day to get approved for all my surgeries. Now I have BCBS of Alabama, they are so slow. My NS wants to have a spinal cord stimulator trial, it took them a month to send me a letter saying it was pre-existing. They have paid for all my back stuff including injections without ever saying my back issues were pre-existing. The insurance company didn't approve or deny my SCS trial, the nurse is going to file it again in December when my pre-existing conditions clause has lapsed. She said it probably won't even take a day to get approval at that time.
    Discectomies 05/08 and 04/11, fusions L4-5 Feb 9,2012 and L3-L4 June 28,2012, Staph infection washout 3/2/2012, Bulged L5-S1. SCS trial on January 17th, 2014, which was a success! Permanent SCS on February 20th.
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