Anthem BCBS just denied lumbar fusion

[mindya]

Hello, I am new to this site and have found comfort just knowing others are out there experiencing the same frustrations as me. I have severe DDD. I had a hemi in '06 L4,L5 and L5,S1, only to re-herniate 5 months later. Since then i have undergone multiple MRI's , CT's, discogram, epidurals, cortizone injections, chiropractic services, massage therapy, etc. The Cortizone injections and pain killers had been helping, but I have reached a point where I can't stand the pain any longer and my quality of life is compromised. My pain management doctor referred me to another surgeon, who is considered conservative. He thinks a fusion can help me and feels it is the best chance for me to live a normal life again. I was set for surgery Nov. 1st, but BCBS had denied the surgery, stating failure to show spinal instability. After trying to avoid another surgery for 4 years and being able to see a light at the end of the tunnel, I have been told my surgery is not medically necessary -- I am extremely depressed and frustrated. My provider is requesting a peer to peer review and doing everything they can to get a reverse determination. Any information/suggestions from those of you out there who have gone through this is greatly appreciated. Thanks - mindya

[Researcher]

Many here can sympathize with you, mindya. I am just about to start the BCBS battle. I have BCBS of Alabama. In my case, I have three level cervical DDD. One look at my X-Ray alone is enough to convince most people. BCBS would cover fusion, but I do not want fusion, since I'm still quite active. I also don't want to risk adjacent accelerated disc degeneration which is common after fusion.

I'm going for Artificial Disc Replacement (ADR) even though BCBS-AL has a specific policy of not covering ADR, stating that they consider the procedure "investigational". There's not much I can do when insurance companies decide that they are going to play doctor. I am still going to have the surgeon submit a pre-certification request, even though there is a 100% probability it will be rejected. This will set the foundation for later appeals for reimbursement of portions of the ADR procedure that are identical to the fusion procedure.

If i were in your position, I would work hard to get more expert analysis of your condition. Throughout this forum, you will find references to excellent spine surgeons in the U.S. and around the world. In my dealings with multiple surgeons, I have found that you have to keep searching until you find the one(s) that really know what they are doing. If you really need fusion, it should be possible to make a case for it. If indeed you do not have a stability problem, but some other problem creating nerve impingement or inflammation, a good spine surgeon should be able to nail it down. If it was me, I would serioulsy consider ADR, although it sounds like Anthem BCBS is not likely to cover ADR either if they are strict on their interpretation of medical necessity for fusion.

I don't feel liked I helped any, but keep searching.

Phil

[Researcher]

Mindya, I also suggest that you contact Marti Conger. She has battled the insurance companies and lobbied the government to get insurance companies to change their policies. I'm sure she can give you very valuable advice. She can be reached at Marti@CongerResources.com.

Phil

[Researcher]

Also, make sure you look at;

The Insurance Warrior, Laurie Todd

and all posts starting with Insurance Intelligencer in;

Health Insurance

Hang in there!

Phil