Blue Cross Denied Fusion - Has anyone been approved with stable spine or for pain?

[gwin]

I was set for a 2 level bi-lateral decompression and fusion of L1,2 and L2,3 plus laminectomy of L3 and L4, but the evening before surgery was notified by my doctors office that Anthem Blue Cross of CA had denied coverage. I have just lost my last appeal. "Not medically necessary" because there in no clear indication of "spinal instability". 24/7 severe pain from L1,2 and L2,3, bone on bone.

I am still trying to fight this, but I need to find other people that Blue Cross has approved for fusion that either had no documented spinal instability or severe pain alone was reason for approval of fusion. Please respond to forum. I would really appreciate anyone who has been approved by blue Cross for fusion feedback. Thanks.

Gwin

[Harrison]

Denied fusion?! Good gosh -- I confess I've not heard of this situation before. My first reaction is, "you're kidding me? What's next from BCBS?!"

This should be easier to appeal than an artificial disc replacement!? Where are you in the next level of the appeals process? In the meantime, your doctor SHOULD be able to argue medical necessity with a much more compelling story -- citing the medical facts!

:sus:

[gwin]

Hi Harrison:

Thanks for the reply.

Yes, this was quite a shock to both me and my doctor, as the diagnosis from more than 10 doctors I have consulted in the past 8 months is severe degenerative disk disease. My hope was to get approved for the fusion, but just have the decompression done at first and work on possible ADR approval, but now I have to fight just for the fusion.

Unfortunately for me, my expedited appeal was the 3rd level and it is over. First was peer to peer, them denial for emergency appeal by doctor, then mine.

I hope to find some out there soon who were approved for fusion (even if you did not go through with it or got Blue Cross to approve ADR's) that did not have documented "spinal instability" or were approved for pain relief reasons.The guildline that was used against me for the denial was the Blue Cross reference "Millman 13th Edition" Lumbar Fusion acceptance section.

When I pointed out in my appeal that the current Millman is the 14th Edition, and the section for fusion acceptance has been updated to include fusion is their is "anticipated" spinal instability in the event of a bi-lateral decompression, which in my case was one of the things that was going to be done. "Anticipated" is a pretty subjective word and could mean a number of things. Anyway, to me it seems it leave the door wide open for fusion approval in my case, but what happened next left me with no other choice than to believe this whole insurance game is rigged.

I received a call from a representative of Blue Cross informing me that my appeal had been denied. All of it, decompression, even though I informed them at the time of the first denial of service, as did the doctor that due to the degree of compression and the symptoms present I could be an emergency medical situation. I asked her how they could use outdated reference material and ignore what the current version says regarding lumbar fusion.

She stated, and I kid you not, that this issue had been sent out for outside opinion, and when I asked what that opinion was, was told that they had not yet received an answer, but that it should come tomorrow. I then asked how they could deny my appeal if they did not even have an answer to one of my key points. She told me their Medical Officer was "confident" that the differences between the outdated and current Millman manuals would be found to be insignificant. Does anyone else see a problem here?

Thanks!

Gwin

[Fred_2010]

GWIN,

Having been denied by both Cigna and BCBS of Nebraska for ADR surgery, I am now scheduled for fusion surgery on Tuesday, July 13th. However, I have not heard whether or not the insurance has approved of the surgery.

I thought that fusion was a sure thing until I read about your experiences. I will post whether or not I am approved.

Fred

[gwin]

Hi Fred:

Thanks for the reply. What is your reason for needing fusion? Do you have an "documented" unstable spine? I look forward to hearing back on your approval, and hope all goes well.

Gwin

[CharlesinCharge]

I had the XLIF fusion in 9/08 and it was approved by BCBS of California, and I do not recall any instability of my spine ever being mentioned. I had "standard" Degenerative Disc Disease (at L3-L4), documented by an MRI and a positive Discogram. I knew that BCBS would not pay for ADR (as they had denied me the first time and thus I went overseas) but getting approved for the minimally invasive fusion was no problem at all---it was a slam dunk. I am quite shocked to hear of your situation, and I would ask BCBS that is you do not qualify for a fusion, WHAT procedure do they suggest you get to fix your situation????

[gwin]

Hi Fred:

Blue Cross reply to me when denied and when I spoke with them was simply " determined your request for service is not medically necessary". They will not offer any option, simply a total denial of service for fusion of the bi-lateral decompression of L1,L2 and L2,L3 plus a laminectomy of L3, and L4.

I have been diagnosed by several doctors with moderate to severe DDD at several levels, moderate to severe bi-lateral and central canal stenosis on several levels, have 24/7 numbness and tingling along with weakness and of both feet and legs, severe lower back pain and recent onset of some incontinence. The numbness and incontinence alone should quality as a medical emergency, but Blue Cross has taken the stand that despite the doctors reports, MRI's, epidurals, pain medications and pain management, etc., there is no "medical necessity" to allow me treatment.

If they can do this to me, they can do it to anyone.

Gwin

[gwin]

Sorry, grammar mistakes, should read "Blue Cross reply to me when denied and when I spoke with them was simply " determined your request for service is not medically necessary". They will not offer any option, simply a total denial of service for fusion of L1,2 and L2,3 and the bi-lateral decompression of L1,L2 and L2,L3 plus a laminectomy of L3, and L4."

[Fred_2010]

GWIN,

I have not heard from BCBS, but was informed today that my wife's employer's coverage through Cigna approved of my fusion of C5-C7. I will follow-up on Blue Cross Blue Shield and get back to you.

I have instability, but don't know that it is documenmted unless it was obvious from my MRI. With the symptoms you describe, I would not give up. Maybe your doctor could try to prove and document instability. Also, maybe other insurance is available not subject to pre-existing conditions?

I was relieved to hear I was approved by Cigna. I can only imagine how you feel.

Fred

[Lauren]

Hi Gwin - Be sure that BCBS is in keeping with Florida law. Most states require that any outside medical professional who reviews appeals must be of equal medical specialty as the doctor recommending the surgery. Meaning that if your neurosurgeon is recommending it, a neurosurgeon must review it. Also, ask around in your own community and amongst those who have the same policy that you do. Fusion is so very common these days, that I'm fairly certain you can find someone nearby who is covered by BCBS and has had the same or close to the same surgery. That failing, go to the Insurance Division of your state and file a complaint and ask for an investigation. That may give you at least one more chance to appeal. If so, see The Insurance Warrior's book on line - buy it and check out the appeal form she provides. Very very indepth and she will give you lots of pointers on how to make sure you get covered.
Good luck to you,
Lauren

[Zymergist]

Gwin,

as you noted that the insurance is CA, I would talk to the folks at the departmant of managed care California Department of Managed Health Care Health Plan Complaints and Appeals (http://www.hmohelp.ca.gov/) . They were amazing for Me and my Wife when we were trying for a birth center rather than a hospital birth. They are expert at deciphering the policy restrictions and verifying that things are being looked at properly. They can likely help with the use of outdated reference materials.

Fight like hell for what you need and good luck!

[jesser29]

I'm also fighting w/ BCBS for a denied fusion surgery. I also got the "not medically necessary" response because I didn't meet their guidelines. Reading your post, I belive they are the updated ones as I recall "anticipated" in the language, yet still, I've been denied after the peer review w/ my surgeon. I do not have 'instability' shown in imaging even though one of my dr's states in my discogram report that instability is suspected.

My surgeon is says there's nothing she can do. My pain dr, who is doing this round of my epidural injections, is researching and fighting the denial. He found that the ins co is pushing back on all these surgeries and he said there are national boards involved...so he's turned it over to them and still is confident he will get it approved. I'm not so sure, but nothing left to do but hope! I haven't sent an appeal letter because nothing I'm going to say is going to change their minds when I can't prove the instability...so I wait......

...and live in pain!

[tatianak2]

I've also been denied fusion at my L5 S1. I'm only 35 and have sciatica running down both legs and severe lower back pain. I have the worst time sleeping and need to take ambien to fall asleep, and I struggle daily to take care of my 2 1/2 year old daughter and regular household activities. I've seen 6 surgeons who say I need the fusion or continue on the way I am. We provided more docs & the doctor requested a peer to peer and they denied me and never honored the peer to peer with the doctor. The doctor that works for BC that denied my claim was a "Dr. Marappa Gopinath". How is it that 1, paid by BC, doctor can deny something that 6 doctors think I need? I have talked to a few attorneys who seem really interested but was curious what you ended up doing or if you found other people like us or who did get approved.

Surgery was sched 12/20 - Denied Thursday Dec 16th and again the 17th
11/09 and 12/10 had two injections which gave bad side effects
Yoga, acupuncture, PT, Chiro, Pilates, Massage, Meds, all very little or no relief.

[jss]

tatianak2,

This is OUTRAGEOUS! Six BCBS contracted surgeons say you need surgery and one says that you don't, means that you have the privilege of living in pain for the rest of your days. Good luck with the lawyers, I hope that something works out; preferable that you get the surgery that the BCBS contracted surgeons say that you need.

I have seen more than a few cases like this, where the insurance company doctor says "NO". In most cases he/she is an OBGYN or something COMPLETELY unrelated to the spine. In your case Dr Marappa Gopinath is an orthopedic surgeon; AND SHOULD KNOW BETTER!

I know that I've not offered you anything helpful. Please keep us informed, and good luck!

Jeff

[DAnn]

Lauren,
Is your story out there in the posts somewhere? Would be interested in hearing more about your conditions and solutions.
DAnn

[Cheryl0331]

bcbs paid for mine. infact they paid for the 1st one and the revision. it depends on the policy.

[CarlaSB]

I am so sorry to learn of your insurance issue with BCBS. I am not sure if this strategy approach will help you in any way, but last year I had A-BC and my spine issues had gotten worse, so I went to see my spinal surgeon in San Francisco. He told me that I needed an ADR, but that BC would not approve it. He said they would most likely approve a fusion, given my history. Only a few insurance companies will pay for an ADR.

I know your situation involves a fusion, but here is what I did:

I asked the spine surgeon's staff for the names of insurance companies known to have approved and covered the surgery he was recommending. One insurance company mentioned was Cigna, which happens to be one option available to us under my husband's insurance coverage with his company.

So I thought, "Why couldn't I switch to Cigna when the enrollment period happens every year in October, then schedule my surgery when covered in 2011?" Since it is the same employer, there is no pre-existing clause.

That is what I did, and now my surgery is scheduled. It was hard waiting almost 6 months for the insurance changeover, but I didn't want to have to pay for this surgery out of pocket.

Obviously, this strategy is only successful if you work for a company that offers multiple choices for your health care coverage- and one of the companies will pay for your surgery. There are many variables depending on your employer and medical plan.

Good luck to you, I hope you will appeal.