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Blue Cross Fusion Denial

Started by jdobs on 08/12/2011 12:45pm

Hi everyone, I am new to the forum but not back issues! I really need some help. My wife has L2/L3 bulging and degenerating discs which are right above a previous fusion from 10 years ago. Unfortunately this happens as a consequence of back fusion but she had no other viable options available to her then. She has been scheduled for a two level fusion 8/23, and of course in true form BC came back yesterday and denied fusion because of "no signs of spinal instability". A discectomy / laminectomy is not an option because it won’t work. She is in agony and will be almost completely unable to move around within six months.
HELP - any suggestions? Attorneys?
We have sent it off to appeals but based on previous experience this won’t help. As a further note I have an L4/L5 herniation and very bad disc degeneration that needed fusion end last year. They did exactly the same to me – denial on same circumstance and refused in appeals. I ended up opting for a laminectomy and decompression which just like the surgeon said - has failed. Herniation is back, in pain 24/7, going on disability and will probably end up losing my house over this whole ordeal with BC. I will be next in line for the fusion I should have had earlier, right after we get my wife sorted out! Thanks everyone – any help would be appreciated. Have a wonderful day.

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I'm in the same situation with United Healthcare. They even gave me the same reason, no instability. Isn't it sickening? Meanwhile, my neurosurgeon tells me I will only get worse and I've exhausted all conservative options. My neuro says that insurance companies have made the fusion criteria so ridiculous that almost no one qualifies. Good luck. If you find a way to make them cover it, please share. :)

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Hi, I'm new here too. I have DDD and use Cigna insurance. I applied for a three level lumbar fusion in Sept. and was denied also. Their reason stated was: patient needs to try "conservative treatment". My doctor and I just laughed as I have had this problem for 15 years! I have tried just about every conservative treatment known. I've had 30 epidural injections over the years. I have had no surgery on my back this far.
I am just blown away by peoples stories on here. How can our system be so screwed up? It makes me sad to hear about people losing their houses and being so far in debt that it disrupts their entire life. Over something they have zero control over. Stay positive is my mantra....just keep on keeping on.
love and light,
angela

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It really is sickening. United Healthcare had the nerve to tell me that they were looking out for my best interests. I had to laugh. They're only looking out for their bottom line. They are very expensive but when you need something they do whatever they can to weasel out of paying. They don't care about their insureds. I don't know how they sleep at night.

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Have had 2 fusion with BCBS and would have never guessed they would deny over a Doc orders?? Baffling to me. My T11-T12 has caused me to loose 1/3 disc thickness in just 2 yrs 3 levels up which is really discouraging but I tested 10 on the discogram, came off the table on the 2nd hit. Never heard of BCBS denial, geez. Sorry

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Hi everyone - I got my fusion approved and am two months into recovery from L4/L5/S1 fusion! I fought Anthem BC and got approval after months of waiting. This is what I did on my last appeal and suggest you try the same:

1. Three second opininions all advocating fusion.
2. Told them pain 24/7 even with percocete every four hours
3. About to lose my job because of inability to work.
4. Will lose home, etc because of them!

PS: Anthem BC has an appeals group called Anthem UM Services. Try 800-365-0609 although this may have changed. The grief and appeals dept. at BC is run by Maureen Prowse, MD.
Stay on them and all the best of luck - I know what you guys are going through. All the best of luck.
Jon.

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Congrats! I'm so glad that you got them to do what's right. I hope I have some good luck with United, though I've lost hope after googling them.

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Nov of 07 had surgery scheduled...2 weeks b4 surgery got a letter from UMR that I was being denied..."no noticeable spinal instability" After 2 years of meds, multiple hospital visits, and i don't know how MANY times of going to PT, they finally approved surgery. So in Sept of 09 I had surgery. Of course it had gone from a 2 level fusion to a 4 level fusion with instrumentation.

Fast forward 2 years...I am STILL on meds for nerve damage, DDD, and arthritis. Have days I can't get off the toilet w/o help. And I have been told that I am at the end of the line for any type of treatment-other than meds to manage the pain.

This won't help you find answers,but at least you will know that you aren't alone in the insurance dance!! It stinks!!

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Just an update. I appealed through the state board of insurance and they over turned United's decision and are forcing them to cover my ALIF. I go in May 22. *fingers crossed*

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Lynn1974, that was a great idea and glad to hear it worked :). I also have UHC and it took a long time including a call with my surgeon to review the case before approval. They were probably tired of paying 15K each time I had epidural injections and decided to just cover the surgery.
Jdobs, my heart goes out to you. Maybe filing a complaint in your state would work for you as well. I wish you the best!

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We tried the peer to peer review, where my neurosurgeon called United's doctor. That didn't work. It took 5 months to finally win. It was a lot of work. Tons of faxing, calling, gathering medical records. United was jerking me around at every turn. After the state bureau made them cover it United send me a letter: "We're pleased to inform you your request has been approved." Ha! I bet they were thrilled. But it turned out ok. I only hope my surgery does too. *fingers crossed*

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jdobs:

I'm interested in your case since you finally got approval from Anthem. We are currently fighting with Anthem over their denial of my wife's 3-level fusion (L4, L5, S1). Their reasons (as typical) "not medically necessary" - since she does not exhibit the instability they require for approval.

Did you you have instability - or were you able to fight and get it approved even though there was no instability present in your spine?

I WOULD LOVE TO FIND SOME EXAMPLES/INSTANCES WHERE PEOPLE WERE APPROVED FOR FUSION (ESPECIALLY BY ANTHEM, BUT ALSO BY OTHER INSURANCE COMPANIES) WITHOUT INSTABILITY.

She has very little disc material left due to degeneration, rupturing, etc. She has had a decompression/discectomy already (not to mention chiropractic care, facet joint injections, steroid injections, a discogram, several rounds of physical therapy and on and on.)

Thanks.

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