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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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Old 01-10-2023, 03:06 AM
badbackkev1992 badbackkev1992 is offline
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Join Date: May 2022
Posts: 1
Default Blue Shield CA PPO-- L5-S1 ADR denied

Hi All


I have been a voyeur on this site for some time now since my worsening lumbar back-pain. A bit of history about my incident for those wondering or who may find themselves in a similar situation:

My back problems started when I was 16 (30 now). I was driving in the busy streets of Beverly Hills, CA, where I was stopped at a red-light in the infamous shopping district intersection of Wilshire and Rodeo (for those familiar with the LA neighborhood). While at this red-light, I was struck at high speed from behind by a college student-- she was texting and driving and had no idea what had happened.

My back bothered me for the next decade or so, but not to the point where I had to seek medical attention, beyond the norms of insurance quack chiropractors. As the years progressed into my mid 20s, I would have bouts where I would bend over the sink to wash my face, and my low-back would ache or somewhat "give out" on me. I would have pain with quick movements where I had to bend down and up.

Fast forward to 2020 and my back pain suddenly got worse to the point where it infected every aspect of my life. I stopped lifting heavy weights in the gym. I stopped playing sports. I stopped getting into fights. My personality changed entirely and I began to tread on the side of caution. Even something as minor as carrying a 20lb bag through the airport had my back on fire. It was at this time I had imaging done, where an MRI revealed a desiccated and herniated L5-S1 with some loss in disc height. I've tried endless sessions of physical therapy, numerous epidural injections including that of the SI joint but all of these gave me very temporary relief.

After seeing more than 8 spine specialists, 2 of them had offered me disc replacements, and 1 offered a fusion. I finally decided to book the surgery with Dr. Alexandre Rasouli for a date at the end of this month.

10 days before my surgery date, I get a call from Dr. Rasouli's billing department. They notify me that my insurance has denied this surgery and that they are requiring 6-months of CBT, which stands for cognitive behavioral therapy. Sounds like a gimmick if I've ever heard one. This was a doctor whom I waited 2-months to get an appointment with and another 3 to get put on his surgery schedule. This destroyed all my hopes and spirits and the plans I had laid out for the year. I had never heard of CBT or any psychological therapy as a means to treat something physically and anatomically wrong with the human body...

So what do I do? I have no choice but to play along and exhaust this option, all the while exploring my avenues. I am in talks with bad-faith claim attorneys; I spoke to a "CBT specialist" today, who told me that this was the first time she had heard of an insurance company requiring this for physical pain. I have requested for her to convey this to my insurance company as well as put it in writing for me to show, which she kindly obliged to do. I have filed a grievance with Blue Shield and requested for it to be expedited.

I felt like I had finally gotten to the beginning of the end with the surgery in my sights and a supposedly excellent doctor, local to me, who has done over 1,000 disc replacement surgeries. I had all my pre-ops done, my bloodwork, CT scans, even spoke with the vascular surgeon and anesthesiologist (who, unbeknownst to me, ended up being out of pocket and not covered by insurance anyways). And now I get hit with this BS. An insurance company that people pay tons of money to each year with the expectation that they can be relied on in situations of medical necessity and need. Quite the opposite.

So just putting this out there for anyone who may be going through the same thing, though I think my story is pretty unique.

Would love to hear your thoughts or similar experiences.


Kevin
Age: 30
Diagnosis: L5-S1 disc dessication, herniation, some loss of disc-height, spinal stenosis, loss of lumbar lordosis, blah blah blah etc etc etc
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