Dear Gene,
Thanks for responding. I can't appeal anymore this is the end of the road.It was the external review that went out to a third party; MCMC.
This is what I expected ,since my doctors said I had positive neurological findings on C4-5 and C5-6; they ALL said that a fusion would definitely get approved. However, a fusion didn't get approved for C 4-5. The ractional was ; " Based on the medical information provided , treatment of the C5-6 level is medically appropriate (either with anterior cervical diskectomy and fusion or artificial disk replacement), as the EMG and MRI report show evidence fo C6 nerve root involvement. The studies do not support the need for treatment at either C4-5 or C6-7. Just because a product is FDA approved, does not mean it is medically necessary."
However, my BC/BS representative said
all procedures have been denied. He said he will call for clarity.
I have three main nerve roots blocked. These results were found through complete positive EMG/NG studies; C6, C8 and T5 show evidence of nerve root involvement.
It's like MCMC from Quincy Mass said since your doctor and you were so greedy and asked for two levels( that have DDD and central canal stenosis that we choose to ignore the test results) now we will not allow surgical intervention! Yes, No surgical intervention at all!
They are saying in a sense that my Blue Cross Blue Shield doctors are incompetent. Forget about what your MRI's, Discograms, CT Scan's and EMG/NG show evidence of ; we are going to deny those findings even though we use them as diagnostic tools when we feel like it!
This is the other point I want to make Wellpoint's (BC/BS parent) profit was 355 million last year. Yes, their profit was 355 million. You mean you can't pay my surgeon or hosipital maybe 25,000 of the 100,000 fee that this surgery will cost? I have cogential cervical and lumbar stenosis. Why do I (we)have to fight tooth and nail to get treatment? I am a 44 year old woman. I am fit, thin and healthy the last thing I want to do is sign up for a MAJOR surgery. I want to be healthy!
Gene, please don't take offense, I am not directing this at you ; but at the state of our healthcare. I saw 12 , yes 12 doctors ! They all agree that surgical intervention is needed! Is B/C B/S saying that they are all incompetent ?
