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| Insurance Hell All insurance-related matters are here: Medicare, worker's compensation, appeals, denials, insights, wins, losses. PRICING is here too. Note: This forum has posts from 2006 forward. Older ones are in the Big File. |
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#1
10-22-2014, 02:25 PM
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Lumbar hybrid surgery/ insured?
Hello everyone!
I need a fusion at L5/S1 and an ADR L4/5. Has anyone had this done and had it covered by insurance? Since Oxford always says no to this even through appeals, I plan on switching to Aetna at the advice of my doctor, he said they offer the best chance of getting it covered. Might get denied and then will have to appeal but if it works I would be more then elated! Over the next month or so I will be preemptively gathering lots of studies, and documents to go to war in case I need it. I also have 6 years worth of images, tests, and failed treatments to show them. If anyone has had this done and covered please let me know, Thanks!! 
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6 year struggle with herniated L4/5 w/ annular tear, ruptured L5/S1 that is now degenerated to where the bones rub, the lack of height is causing the facet joints to degenerate and cause pain at that level. Stenosis and radiculopathy to the left leg also present. Now waiting to switch insurance so that I can get a hybrid surgery. Fusion of L5/S1 and ADR at L4/5. 
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#2
10-23-2014, 07:26 PM
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He's Right
BCBS and most others will fight you as long, as the day is long.
I fought them for 9 months, and lost, I went to ONZ, Germany, had just what you said, Hybrid, more on that in a moment, and now the insurance is fighting me on the payment for the surgery, they paid for the hospital stay, their share, but I will appeal the payment for the surgeon's fees. . I went, originally for a two level, M6, and they could not access the lower level, L5-S1, so they offered the PLIF, I accepted, this was the major pain generator, and I really did not see an option. If I had been in the USA, I most likely, with Communist Health REGULATIONS would have had to pay for the second surgery, FULL PRICE. . Even Aetna will fight you, if you do not have it done in the USA.
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Jerry, Somewhere Ohio L2-3 herniation, two days before Thanksgiving, 2012, Discectomy/Laminectomy, 3/13 Numbness in the right leg, lateral femoral, gone, July 10, 2014 L45 M6 ADR, July 15 PLIF L5-S1, Not able to access L51 Anterior.
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#3
10-24-2014, 02:12 PM
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Hi Jerry,
Yes, I really have no plans on going over seas for surgery, I am going to try my darnedest to get it covered here. My surgeon didn't sound to worried about the surgery not getting covered so it makes me wonder if they have their "ways" of getting the surgery approved. I will be ready for a fight, though, if I need to appeal. How are you feeling by the way with your hybrid surgery, are you happy with it and doing well?
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6 year struggle with herniated L4/5 w/ annular tear, ruptured L5/S1 that is now degenerated to where the bones rub, the lack of height is causing the facet joints to degenerate and cause pain at that level. Stenosis and radiculopathy to the left leg also present. Now waiting to switch insurance so that I can get a hybrid surgery. Fusion of L5/S1 and ADR at L4/5.
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