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Blue Cross Denied Fusion - "No spinal instability"

From: gwin - on 07/04/2010 8:36pm

I was set for a 2 level bi-lateral decompression and fusion of L1,2 and L2,3 plus laminectomy of L3 and L4, but the evening before surgery was notified by my doctors office that Anthem Blue Cross of CA had denied coverage. I have just lost my last appeal. "Not medically necessary" because there in no clear indication of "spinal instability". 24/7 severe pain from L1,2 and L2,3, bone on bone.

I am still trying to fight this, but I need to find other people that Blue Cross has approved for fusion that either had no documented spinal instability or severe pain alone was reason for approval of fusion. Please respond to forum. I would really appreciate anyone who has been approved by blue Cross for fusion feedback. Thanks.

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on 07/08/2010 9:56am

I am a board certified radiologist that has been performing computerized analysis of spine xrays in the evaluation for spinal instability or ligamentous injury. The test (computerized radiographic mensuration analysis) has been used for many years and is highly precixe, accurate. If I can be of further help please email me at scanman818@aol.com.

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on 07/14/2010 11:22am

Blue Cross has been denying my fusion for 3 years. I wish you all the best, hope you have better luck than me!

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on 07/14/2010 7:10pm

Wow! I wonder how I missed this post.

So, how does BCBS get to decide this inspite of the doctor's decision? I have BCBS too and am a bit worried.

So far they have been paying all of my bills with out a single issue.

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on 07/15/2010 2:54am

If there is no spinal instability then you don't want the fusion. The fusion will end up giving your more pain. You may still want the decompression (which is also called a laminectomy) but at this point I would want another Doctor. What the fusion would do is add metal braces and screws going into the bone to stabilize and immobilize the spine.

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on 12/16/2010 7:42pm

Did you ever get any updates on this?

I was just denied spinal fusion at my L5 S1 for the exact same reason, yet 7 orthopaedic surgeons believe I do need it! I don't know what to do.

Tatiana

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on 12/26/2010 12:30am

Hey gwin - I'm so sorry to hear you're having so much trouble with the insurance company. Is BCBS your regular medical insirance or is this a work comp issue?

My issues was a work related injury, I was sent to This Dr and That Specialist Dr. all of them in fact saying I needed surgery to repair my c-spine .... and those were the dr's that their (my ex employer) insurance company sent me too. I did a couple rounds of PT as well as epidural injections. Back in June of 2010 I saw the surgeon, he recommended a double discectomy with fusion at c-5/c-6 and c-6/c-7. By August 2010 the insurance company denied the surgery.

I fianlly did obtain a lawyer (people had been telling me to get one for months, and I was against it) went to court and won the case hands down. They have to now pay for the surgery as well as my temporary disability until all this is resolved. I didn't know until Aug. of this year that my insurance company was ranked #1 worse bad faith insurance company for many years in a row. They would deny, deny and then put off hopeful that I would just go away. My injury date was Nov. 2009

If you don't have a lawyer, at least concider it, get a free consultation from a couple different ones even, but don't give up. Like I said, I was againt getting a lawyer, now I think differently.

Hope this is resolved soon for you, I hate to hear about others being in pain, and getting a run around ... I know all to well about the pain and the frustration with insurance companies.

Jenn

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on 12/27/2010 12:40pm

My comment is to Jenn45, I saw that you posted you are a work comp case. Was wondering if I could ask few questions. I am also a work comp and need 2 level fusion from l4-s1. If you wouldn't mind please email me or send me you email. Mine is medwards68@hotmail.com Thanks

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on 12/28/2010 8:47am

As sad as It is to say but BlueCross is denying fusions at a rate thats unreal. There was an ad in the Newspaper that said they had paid out millions of dollars in fusions that they felt were done that were unessary according to their doctors who reviewed the records.. According to the article they are gonna do fusions only for certain spinal conditions such as scoliosis, or tumors.. DDD and instability must be submitted by the neuro/spine doc to an independent doctor to review and must agree with the referring doctor to authorize the fusion.. Medicare/Medicaid are also starting to use the same standard and the other ins companys ie: UHC, Aetna etc are reviewing their protocol as well.. I guess we as Americans have no right to appropriate healthcare.. If we lived in Canada or another country where ins is provided at no charge maybe we wouldnt face this dilema.. I had a discogram done 2 weeks ago and I am scheduled to have a PLIF in January.. It was originally thought my pain was from the protrusion that was on the nerve.. If I hadnt had a thorogh doctor who was my 3rd opinion I would have had a micro-diskectomy on l5-s1 and I was told that would have failed due to the IDD and teras in the disc that the discogram showed.. i have UHC and they have approved the PLIF or the ADR which ever that was decided to do.. I will be responsible for 850.00 total out of a 100k surgery.. I switched from BCBS 1 yr ago for other easons and now I am glad I did.. Good luck to all who need this done and BCBS denies.. Be persistent!!!

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on 06/02/2011 9:34pm

I have Spondyloletheses, unstable, with severe pain at the lower back, pinched nerve, and pain down both legs and Blue Cross just denied my surgery a few days ago. I googled and found all your posts about Blue Cross denying them surgery. This is very upsetting. I am wondering if anyone has contacted an attorney? This isn't fair. I am in so much pain and am at a lost as to what to do now.

This is an update on 06/02/2011 - Blue Cross finally approved my Spinal Fusion and I am now 8 weeks postop and feel great! Best of luck to everyone who is still trying to get help.

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on 02/24/2011 11:10am

Sounds like Blue Cross has Spinal Instability! I'm sorry for your troubles. I wish I knew more people to help back up your case.

I have a feeling everything will work out for you.
Have a wonderful day!

-Grace

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on 06/02/2011 8:55pm

Hi gwin, saw your post & wanted to reply & let you know I have Blue Cross/Blue Shield of Iowa & they approved my fusion with no problem. My husband works for a company from Iowa but we live in Texas.I had 2 MRI"s to document all that was wrong with my back. I had a minimally invasive fusion on the L-3,L-4, L-5 done on Jan 2011. I looked through my BC/BS webpage & found who was in my network & read what was covered & what wasn't. Hope this helps. Good luck. Tessa

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on 08/12/2011 1:26pm

Hi, Can Jenn45 tell me what type of attorney she used to take BCBS to court?

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on 08/12/2011 4:18pm

Hi,
I have spoken with a number of doctors after my surgery and appeal for fusion was denied. Now my wife's request for fusion is going down the same rat hole with BCBS.
PLEASE can someone advise of a good attorney in So. Cal...I think it may be the only way.

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on 06/19/2012 5:38pm

#suzncal just wondering what you did to finally win the appeal. OR if anyone has any advice please help. My mom is in need of this surgery and has been denied by blue cross in CA. We are putting together an appeal and need to know if anyone's won and how???

PLEASE HELP!

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on 06/20/2012 10:37pm

blue cross is good at denying everyone keep at them mite get the insurance commision after them

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on 06/21/2012 6:56am

I had 2 fusions done by BCBS of NC in '09 L5-S1 which I consider a success as that disc was in 3 pieces but my T11-T12 XLIF has caused me to loose almost 50% disc thickness the next 5 levels up in only 2 yrs. I would have sought out every other option for that if I had only known then what I know now as overall all I have endured 2 fusions and 4 other surgeries since '09 and am basically just as bad now as I was then just with 5 more levels to live with. I'm DONE with surgeries until they come out with a better idea. I'll manage my pain and try to learn to live life like this but I am P'd off and pretty dang depressed. Pain is one thing but the ungoshly spasms I have are the most debilitating thing I have ever endured and you don't get used to them.

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on 06/22/2012 5:10pm

I went through the same thing with United Healthcare. I don't know what state you're in (I'm in Virginia) but after United denied my final appeal due to no instability I filed an appeal with the State Bureau of Insurance. They sent all of my records to an impartial board & the board's neurosurgeon over turned United's decision & the State Bureau forced United to cover it. I had my ALIF done a month ago today. I didn't need a lawyer. I handled it all myself. It took 7 months & it was a lot of work but don't give up! Most people do and the insurance companies count on that. I'd be happy to help or answer any questions you may have. Keep fighting & good luck!

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