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3 herniated disks.. BCBS wants to pay for 2 fusions

Started by SP on 10/18/2010 8:14pm

Hello everyone,
I have been living with this for years and finally had enough with the pain. Its got much worse in the last few months. I get a persistent burning and aching in my right side abdomen. One surgeon thought it was muscular. I just had a discogram done to see how many discs were causing the pain. They injected the die into 4 of my disks in my lower back. 2 came back with pain. L5/S1 is bone on bone :--( I have tried everything for pain(epidurals, physical therapy, chiropractors, meds, acupuncture.)

Anyways my surgeon wants to do a fusion on the L5/S1 and wants to do a replacement on the disk above L5/S1. But BCBS want to only cover 2 fusions. I dont want 2 fusions if I dont need the other fusion. The surgeon also said that the cost is comparable on the fusion. I wend to 3 different surgeons the last few years. I also see a pain management Dr. I take 10/325 percoset 1-2 times a day.

Is there something I can do to get the insurance company to pay? I called my local union office to see if they can help. I should hear back from them in a few days. I have Blue Cross Blue Shield EMHP.

thanks sorry if I rambled on.
Shawn

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anyone have any advice? comments ? thanks

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I don"t know any thing about insurance but I have had two disc fusions they were less then 2 years aparts.s1/ L5/L4 was my first with a disc replacement , then 23 months later where the rods were connected to L3 it hernated the docter told me this will not be my last surgery so I'm praying for you. GOOD LUCK WITH YOUR INSURANCE, YOU MAY HAVE TO DO WHAT EVER THEY SAY.

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I have Wellmark BCBS. My spine doc fought tooth and nail for me to get a disc replacement. Eventually he buged them enough they agreed to pay for the single level disc replacement. I dont know how your doc is communicating with BCBS, but I hope he willing to do what my doc did for me. I didnt have to do anything but show up for the surgery. It was a ProDisc that was used to replace my L5-S1 disc. I still have herniations at L3-L4 and L4-L5. Im going for my 1 year check-up tomorrow, and I plan to discuss what to do for the other herniations. Im scared that the only option I have left would be a 2 level fusion. Oh ya, the ProDisc has done its job well, no regrets.

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[quote]I have Wellmark BCBS. My spine doc fought tooth and nail for me to get a disc replacement. Eventually he buged them enough they agreed to pay for the single level disc replacement. I dont know how your doc is communicating with BCBS, but I hope he willing to do what my doc did for me. I didnt have to do anything but show up for the surgery. It was a ProDisc that was used to replace my L5-S1 disc. I still have herniations at L3-L4 and L4-L5. Im going for my 1 year check-up tomorrow, and I plan to discuss what to do for the other herniations. Im scared that the only option I have left would be a 2 level fusion. Oh ya, the ProDisc has done its job well, no regrets.[/quote]

Very interesting, My doctors office said they fought in the past with BCBS (across the board)and got nowhere. It does not seem like they want to try anymore. I may need to go to another surgeon or nag them more. This is good ammunition for me to keep pressing the issue.. Right now my union has been working on my case for me. Thanks for posting this. Thank you so much again.

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Shawn

Start doing the emergency exercises athttp://www.crookback.com.au/emergency_exercises.htm 2 hours a night for a couple of months and see what happens. It's highly likely that your pain is not caused by a lack of surgery.

There is an advert on this websitewww.nomoreback pain.com. Mr Cannone has a very good reputation.

Go to the Egoscue Back Clinic in San Deigo -www.egoscue.com Mr Egoscue's reputation is second to none. Get his book Pain Free before you do anything else.

Try outwww.globalbackcare.com Send them some photos and they may give you an insight as to what's causing your problem. If you use the contact form and ask nicely they may do it for free.

Spending $100 (in total) at these sites may well save you an absoulte poultice. The insurance company won't have to pay a thing.

Regards

Nikon

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Yeah thanks Nikon. I'm a PT. There is no exercise in the world that will fix this.

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Shawn,

You can fight BCBS and win. In fact they lose most appeals but the denial that are not appealed saves them money. Call them and tell them that you need the procedure for appealing the decision. Also ask to whom you should send your doctor's letter where he recommends doing it right,

Good luck man. No worries on the ramble. It was actually concise especially given what you are going through. You can win this fight. If the appeal does not work, or you stil an't get disability contact me again. I will help you out via email or phone.

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Shawn:
I see plenty of people with 2 level fusions that do well and have done well for years. Honestly, I am a PT as well, and I don't know that I would have a disc replacement. depending on my age at the time of surgery (mainly concerns about child bearing) I would opt for an anterior fusion. Looking at outcomes, I just don't see anything that convinces me that a disc replacement is a better option and there have been problems with artificial discs. I know several surgeons at major teaching institutions that recommend against the disc replacements at this time (or at least up until a couple of years ago). Despite the incredible horror stories I read over and over on spineuniverse, I have to say, the problem isn't the type of surgery, in my experience it is the selection process. If you are convinced you need a fusion and/or disc replacement, either the surgeon needs to convince the insurance company that the disc replacement is a better option or needs to objectively give you why one procedure is better than the other. Best of luck with your decision--I happen to be a big believer in surgery when conservative measures have failed AND there have been sufficient tests to identify that surgery is a good option (discograms, selective nerve root injections and sufficient conservative interventions by knowledgeable and skilled PTs that effectively can treat the non-surgical stuf)f. If that has been your experience, you should be confident of an excellent outcome!

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call your state insurance commissioner, they will do a ruling if you file a complaint. they will have your dr verify you need this done.

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I Just had a Disc replaced at the C5-C6 level 12/7/10. I actually had the option of the replacement disc or the fusion. The "only" reason I had the option was that there was NO Arthritis in my neck. If there was Arthritis in my neck then the only option would have been the fusion. I have BCBS. They did approve the replacement. Maybe thats the reason.

Or, I'm guessing - that BCBS is fighting it because they will fuse one and replace the next level up. In which case being more than one level, if it doesn't work out well and the replaced disc may have to be removed and fused anyway - they potentially wasted their money. I know on my BCBS statement there was a charge of $10,000 for medical equip/supply. The Disc.

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