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Insurance Co Approvals for Fusion

Started by Lynn1974 on 11/01/2011 3:02pm

I have a herniation at L5-S1 with a grade 5 annular radial tear. After exhausting all conservative and even a few alternative treatments (some of them very painful), my neurosurgeon recommended an ALIF fusion. My insurance company has denied it because there is no "instability" and no compression of my nerves and spinal cord. I have a positive discogram and two MRI's that show the problem. We're appealing but I'm so frustrated with the whole process. I don't know what to do next. I would greatly appreciate any advice. I'm beginning to feel that there is no hope. Thank you!

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So sorry to hear this. I had same problem and had a spinal minimal evasive fusion March of this year. Mine was a workcomp case, but it took over 6 months for them to approve it. Longest time of my life. Don't give up! Has your dr written to the insurance company in the appeal process? Wish I knew more to help keep fighting, very happy with my surgery results. I also had a discogram which was positive as well. Many epidural shots, pain meds, and I even had to endure a joint block which was to rule out joint pain, ugh that one was a killer too. Have you tried to get into Physical Therapy? A therapist has many things that can help while your waiting for your appeal process. Tens units are great, heat, as well as they used infra red light which helps with pain too. They can also help you with exercises which can help minimize the pain. Sorry wasn't much more help!

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Thank you! It helps to know that I'm not the only one. I've done physical therapy, chiropractic, decompression and the shots. I even let them use this experimental methylene blue dye during my discogram that was supposed to help regrow tissue. No luck. I've also tried the back brace. My doctor recommended a tens unit but my insurance company refused to cover it. Apparently United Healthcare is notorious for denying fusion. My doctor's office said that they are always the most difficult out of all of the insurance companies they deal with. It's so frustrating. We are appealing. My neurosurgeon is calling their doctor to do a peer to peer today. When that doesn't work they will file an official appeal. They've told me not to get my hopes up, though. They said less than 50% of appeals with United are successful. I wish the people at United who made these decisions could have to live with the pain I have on a daily basis, just for a day. They tried to tell me they denied it because they were looking out for my best interest. Ha! I have 3 doctor's who all say I need it but they'll just present 4 on their payroll who will say I don't. It's my only option. There's nothing left for me to do. So beyond depressing.

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Just from some other discussion groups I watch I have read if you really go after the insurance company,
naming the company on Facebook or other sites, you usually get a quick call from the company approving
your request, especially right now when everyone is looking at their Medicare plans for 2012. Its worth a
try and have all your friends on Facebook share with their friends. That way it gets widely distributed and
will probably get the insurance company's attention. They want their clients but don't want to pay up when
the clients really need the services their physicians recommend. Lynda

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I've done that on a small scale but I need to do more. Thank you for the reply! This has been beyond frustrating. The thought of being in so much pain forever is more than I can bear.

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hi lynn sorry to hear the problems with your insurance, of all things to happen this isnt a good one. I checked with my insurance and my surgeon got a pre approval , my surgery is on 11-28 im getting impatient. im getting a decompressive lumbar laminectomy L1-L4 with a L1 thru L4 fusion expedium bonegraft allograft possible transverse lumbar interbody fusion. sounds like a days work. I have been in pain all but 19 years of my life. but hang in there hope and pray they will come around for you.

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Thank you! Hope all goes well for you. I can't imagine dealing with this for that long. I really feel for you. So far things aren't looking good for me. My neurosurgeon did a peer to peer consultaion with the insurance company's doctor and he denied it as well. We have to file a formal appeal but my surgeon's office doesn't seem to feel we'll have much luck. We're going to do it anyway. They also just refused an urgent care visit I had because it was "out of network." From what I understood, no urgent care's were out of network. I have never had this many problems with an insurance company. United Healthcare really is the worst.

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hi lynn I cant rember if i comented on the subject before I have humana insurance and so far they have been there for me you may want to go to someone that knows insurance and see what you have it was nov 28th 2011 when my back surgery wasI had pain when surgery was over. now the pain has went away and it feels good no more vicoden. i havnt got the bills yet but im guessing that the expense is going to be around 50,000 or more i spent 3 weeks in rehab and a week in the hospital. it can get expensive.

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Thanks for the info. I hope things continue to improve for you. My situation has only gotten worse. United must be the worst insurance provider on the planet. They denied my appeal and the letter that was sent listed all of my treatments, including cortisone shots. At the end of the same paragraph it said "Patient has no history of epidural steroid injections or other conservative treatments." I had 3 rounds of the shots and United covered them all! They contradicted themselves in the same paragraph. When I called them to point out their mistake they asked me to send them some additional medical records. I did and then received two letters from United. One said "We received some medical records from your provider but we're unsure why you sent them." Because they asked me to! The other letter asked me to have my doctor resubmit a request for authorization. My doctors office did and received a phone call from United asking why they sent it. Because they asked them to! Today I spoke to a nice lady at United who was sympathetic, but she told me that my denial had nothing to do with what kind of treatments I've had and she'll resubmit the request but it will be denied since nothing has changed. She suggested that I try to get a laminectomy. I have a feeling that they will just deny that too. At this point I have no faith in United at all. The neurosurgeon who reviewed my case and denied it obviously didn't review all of my records and if he did he didn't pay attention. Throw in all of the conflicting statements and I'm ready to scream.

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So, I finally got approved! After 5 months of being jerked around by United I filed an appeal with the state bureau of insurance. They sent all of my info to an impartial board. They overturned United's decision, said it absolutely is medically necessary and are forcing United to cover my ALIF. Now I'm just waiting to get it scheduled. :)

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lynn thats great good luck with your surgery.

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Thank you! I'm nervous but I'm hoping this will be a solution. I know I have a long road ahead of me. I don't expect to be totally pain free but any improvement would be huge at this point.

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Good Luck Lynn. I'm one year out from my l5-s1 surgery. I am receiving a settlement from my work since I was injured on the job and unable to return to work. Be prepared the first few weeks after surgery are rough, they were for me. Prior to surgery I was probably at a 9 for pain but not its about a 2. I do take tramadol 50mg twice a day. The only time I would say things are really rough for me is when that time of the month approaches or I just do too much. I don't think anyone is 100% after surgery but your quality of life will definetely improve. Be sure to get physical therapy as soon as your dr will allow it, it does help. Keep us updated and I will be praying for a successful surgery.

Maryann

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Thank you, Maryann! I'm trying to be cautiously optimistic. I know it's going to be pretty rough for a while. I'm afraid of the surgery but I'm more afraid of not only feeling this bad all the time, but getting even worse. I'm glad you've seen so much improvement! I hope I have similar results. I'm scheduled to go in in late May. It seems so far away right now. I just want to get it over with and start working to get my life back.

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