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 I asked her how they could use outdated reference material and ignore what the current version says regarding lumbar fusion.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 She told me their Medical Officer was "confident" that the differences between the outdated and current Millman manuals would be found to be insignificant.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
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