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

[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 . 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 They can likely help with the use of outdated reference materials.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.