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Lumbar fusion denied, wanting to sue? PLEASE HELP, NEED ADVICE

LaurenBrianneLLaurenBrianne Posts: 25
edited 09/17/2014 - 4:38 AM in Health Insurance Issues
I'll start with a summary of my story. It all started about 2 weeks after I gave birth to my little girl. At 19 years old, I was diagnosed with a herniated disc at L5-S1 and degenerative disc disease. After that, I tried chiropractic therapy, physical therapy, and injections. I finally got a discectomy/laminectomy in January of 2012. I was alright for about 6 months, and then I started having horrible sciatic pain all the way down my leg, muscle spasms, and back pain that prevented from even bending far enough to put my little girl in her carseat. I went back to my neurosurgeon and got an MRI which showed that my disc space had collapsed and the degenerative disc disease was doing it's job. I've suffered ever since and gone through multiple sets of epidural and SI joint injections. My surgeon suggested a fusion and I decided I've had enough and want to do it. Well, the insurance company denied it. So we did an appeal. Once again, denied. So he did another appeal, and it was denied again. They now say it's over and there's nothing else to be done, but I know I need this fusion. I just want to get it so bad and try to take my life back. I'm sick of taking the pain medications and goin through the injections. I called a lawyer and want to try to sue the insurance company and am hoping that maybe they will just approve it so they don't have to deal with a lawsuit. Can anyone give me any advice?? Will suing them help? Is there ANYTHING I can do to get this fusion approved?? I'm only 21, so my surgeon says if I don't get this fusion my spine could degenerate at a very young age and he believes this fusion to have a 100% success rate. I have no idea why my insurance deems this surgery to be not medically necessary. I've also thought about just dropping the HealthLink insurance and seeing if my medicaid will take care of it, since the HealthLink is my father's insurance and I'll be dropped from it in a few years anyway. Can anyone help me and give me some advice on what would be best??
Lauren Davidson


  • Lauren - any doctor who says there is a 100% success rate for fusion is not being truthful! Statistically speaking, fusions are 50/50 for pain relief. Just because you get a fusion doesn't mean you are pain free afterwards. I had a two level fusion 7 years ago and I'm on strong narcotics and muscle relaxers just to get through the day. I HIGHLY recommend you get a 2nd opinion from either an Orthopedic or Neurosurgeon regarding your case. All suing is going to do is make some lawyer heavier in the wallet and you with remaining pain. If you have questions, feel free to send me a PM. I'll try to help you any way I can.

    Several Epidurals, L4-S1 360 ALIF, Numerous Facet Joint Injections, RFA x2
  • An insurance company approving it just to avoid a lawsuit? It is the opposite..... They'll invite the lawsuit and wait it out.

    There are so many different ways to deal with pain.... Hopefully Sandi or Liz will chime in soon with some good links for you to start off with!

    Wishing u the best and sending healing vibes your way!

    4 Level (C5-T2) Posterior Instrumented Fusion w/ Decompression (Car Accident in January 2014)
    And I can't forget that I'm not ashamed, to be the person that I am today.
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  • LizLiz Posts: 9,745


    Veritas-Health Forum Moderator

    Spinal stenosis since 1995
    Lumber decompression surgery S1 L5-L3[1996]
    Cervical stenosis, so far avoided surgery
  • my lumbar fusion was denied as well. we fought and the insurance company basically ignored me and my doc. they claimed it wasn't medically necessary, and were willing to cover the cost of a laminectomy instead. didn't want to hear reasons for why that wouldn't work. it also didn't seem to matter to them that i had already had 2 laminectomies in that same location, paid for by them, and they didn't work either. but it took complaining to their corporate offices to get my surgery approved. it was a whirlwind situation with approval 5 days before my originally scheduled surgery (which had already been cancelled.) thankfully OR spot was still open and they could get me in for pre-surgical testing on a friday before the monday surgery. but as far as my insurance goes, it is still listed as not medically necessary. but they paid the bill.
    Microdisectomy / hemi-laminectomy 6/2010 and revision 10/2010
    Cervical fusion C4-5 and C5-6 9/2011
    Lumbar Fusion L5-S1 6/2012
  • I gotta laugh when insurances start trying to make it sound like they know more than the doctor treating you. As if they know more than doctors. I sure hope those that try to play God have some sort of medical degrees that makes them so much smarter than the doctors. We pay for the insurance- they should provide the services that are needed. IMO
    Tracie C
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  • as medically unnecessary, it is done with a consult by a physician who looks at the information provided, and the imaging reports, and reports from your physician.
    Based on those things, a determination is made regarding whether or not a particular procedure is in the patients' best interest.
    While doing a fusion sounds like it could be the answer to your prayers, it is not , and it should NEVER be done for pain relief.......it should ONLY be done when it is needed to fix a mechanical or nerve compression problem , after all conservative measures have failed. If your sole purpose to wanting this surgery is that you believe that the surgeon's 100% success rate is going to cure your pain, you are heading into surgery with the wrong doctor and with the wrong idea of what the reason for the surgery is.....
    I would RUN, far and fast from any surgeon who promises you 100% anything when it comes to spine surgery......
  • I agree with all the comments above. My neurosurgeon told me ANY fusion surgery is a 50/50 shot at pain relief. He also said that a lot of the horror stories you hear from patients that the surgery didn't help their pain, or they got worse, are from patients from doctors that had no business doing surgery on them in the first place. This of course isn't true for all situations, but no doctor can promise 100% relief, and suing anyone isn't going to get you any further. I'm lucky enough to have a doctor that is being completely honest. I am 35, and I understand what its like to be young and in pain. Back surgeries aren't black and white like and an appendectomy. Most patients have multiple problems and a lot of "grey" area that makes it harder to fix the problems.

    Retrolisthesis C4 of C5 and C5 of C6
    Spondylolthesis C5/C6
    Disc protrusions with Annular Tears C3/C4, C4/C5, and C5/C6
    Disc Material Compressing Spinal Cord C3/C4
    Severe Forminal Stenosis C5/C6
    Ankylosing Spondylitis 
    Annular Tears L3/L4 and L5/S1
    Enlarged Facet Joints/Facet Anthrosis L3/L4/L5
    PLIF with Rods, Cage, and Pedicle Screws-L4/L5
  • I would agree with the comment that Insurance Companies should not practice medicine. The people at BCBS tried to tell me that it may be in my best interest to deny the surgery.

    It simply comes down to they are trying to minimize their costs.
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