Blue Cross Denied Fusion - Has anyone been approved with stable spine of for pain?

[gwin]

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.

Gwin

[KBear]

Wow Gwin, I have never heard of someone being denied fusion. I was denied ADR and told they would pay for fusion. I am sure more people will get on with advice, but I'm at a loss. Maybe get approval letters of others having fusion paid for by BCBS with your condition. oh, and welcome to the forum, sorry for the circumstances.
Kathy

[gwin]

Wow Gwin, I have never heard of someone being denied fusion. I was denied ADR and told they would pay for fusion. I am sure more people will get on with advice, but I'm at a loss. Maybe get approval letters of others having fusion paid for by BCBS with your condition. oh, and welcome to the forum, sorry for the circumstances.
Kathy

Hi KBear:

Yes, this was quite a shock to both me and my doctor, as the diagnosis from more than 10 doctors I have consulted in the past 8 months is severe degenerative disk disease. My plan was to get approved for the fusion, but just have the decompression done at first and work on possible ADR approval, but now I have to fight just for the fusion.

Your idea of posting here in hopes I can find others who Blue Cross did approve for fusion is exactly what I am trying to accomplish. If I can get at least 20 documented cased that they did approve, without what they call "documented unstable spine" and / or for severe pain alone, that would be very helpful. Please share your Blue Cross fusion approval or denial story. Thanks!

Gwin

[Cindylou]

Wow, I am so sorry Gwin, that you are finding yourself in this position of fighting for even fusion.....let alone the night before your surgery they called and canceled! Unbelieveable. I don't have Blue Cross so can't help you with that, but hang in there. You should hear from some folks who achieved "approved" status soon.

[KBear]

I just read another thread where Greg said they were going to deny him fusion. I'm sure he will pop in soon and comment. Not sure who his insurer was.

[gwin]

Hi All:

Thanks for your comments, and I hope to find some out there soon who were approved for fusion (even if you did not go through with it or got Blue Cross to approve ADR's) that did not have documented "spinal instability" or were approved for pain relief reasons.The guildline that was used against me for the denial was the Blue Cross reference "Millman 13th Edition" Lumbar Fusion acceptance section.

When I pointed out in my appeal that the current Millman is the 14th Edition, and the section for fusion acceptance has been updated to include fusion is their is "anticipated" spinal instability in the event of a bi-lateral decompression, which in my case was one of the things that was going to be done. "Anticipated" is a pretty subjective word and could mean a number of things. Anyway, to me it seems it leave the door wide open for fusion approval in my case, but what happened next left me with no other choice than to believe this whole insurance game is rigged.

I received a call from a representative of Blue Cross informing me that my appeal had been denied. All of it, decompression, even though I informed them at the time of the first denial of service, as did the doctor that due to the degree of compression and the symptoms present I could be an emergency medical situation. I asked her how they could use outdated reference material and ignore what the current version says regarding lumbar fusion.

She stated, and I kid you not, that this issue had been sent out for outside opinion, and when I asked what that opinion was, was told that they had not yet received an answer, but that it should come tomorrow. I then asked how they could deny my appeal if they did not even have an answer to one of my key points. She told me their Medical Officer was "confident" that the differences between the outdated and current Millman manuals would be found to be insignificant. Does anyone else see a problem here?

[Greg]

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.

Gwin

Gwin,

I am so sorry you have entered the world of what I liked to call "blue-cross-bull-shittedness" Unfortunately I was in your exact same shoes near the end of last year I thought that which such an arbitrary denial of legitimate, standard, covered and necessary services that surely they wouldn't do this to anyone else......I hate to be wrong I had DDD at L4/L5 (bulge with annular tear) & L5/S1 (herniation abutting the bilateral proximal S1 nerve roots, larger annual tear) and had every bit of documentation to prove it; MRI, Xray, Discogram with CT, yet the insurance BCBS of VA (I live in NC) decided to deny me for fusion because there was "no evidence of instability." I tried several appeals to no avail; first one my dr wrote and I was so impressed from the letter he wrote because it threw everything back in their face showing how wrong they were and you could definitely sense the outraged tone of his voice in the letter.

Do not get discouraged and think there is no hope......their is, I just had my 2 level ALIF on 6/18/10 I slipped into some bad depression after my denial and loss of hope. I lost every appeal I tried and wanted to give up on life. You sound like a fighter and I am more than happy to help in any way possible. I have most all of the paperwork relating to the appeal, denial, then out-of-the-blue approval 6 months later put together but I need to get some more stuff put together for you. And I am still at home recovering from surgery so I will see what I can do about getting all these documents into an electronic format for you.

Once I gave up on life and realized that there is no way I am going to get the standard of care most other humans receive for the pricey insurance premium payments we make, I started back to looking for clinical trials doing fusion to find a way to get surgery....Not easy as most fusion clinical trials dont pay for the surgery because a lot of them are testing new equipment or hardware and are for people already undergoing fusion (paid for by their own insurance). I finally found a trial (they use stem cells to aide the fusion, Durham NC but I think it was a multi-center trial) that would pay for the surgery if my insurance wouldn't. They couldn't believe I was denied for fusion as they have never heard of that and fused many patients with much healthier backs than me. They still had to try to get approval. The surgery scheduler spent 15 minutes on the phone with BCBS doing a pre-auth by phone call, not submitting a letter and with it being a phone call she didn't submit any documentation to back up my claim, just spoke about me and THEY APPROVED THE FUSION! Just like that....I couldn't believe it. And it proved my theory even more that they denied me last year because I was at my out-of-pocket cap already (surgery would have been 100% paid for) and were trying to hold me off until the next year (couple months away) so everything would reset and I would have to pay for some of the surgery. I have a thread I started after the approval which explains more. How dare they do that????

Have you met your out-of-pocket cap for the year? That seemed to be the reason they denied me but who knows....insurance companies have no rhyme or reason. What seemed to be the trick to getting me approved (because I had exhausted all appeal efforts and they sent me a letter saying the appeals are over and this case is considered closed) I went to a different doctor who tried to get approval....once you get an approval for the surgery you can go to a different doctor. But if you try this (if the appeals dont work or just feel like trying) have that doctor office try and do the pre-auth by phone call, not by submitting paperwork....thats what seemed to be the trick that did it for me. I even had diagnoses that claimed would make me eligble for the fusion but they still ignored everything. I wish you the best of luck and I will help in anyway I can. If you want to chat about this PM me and I'll give you my phone number because sitting up and typing for long times irritates my back right now.

I am so, so sorry you are going through this. You can turn this around though, you just have to persist until you succeed and I am willing to help.

[Susanna]

Greg,
Am I to understand that you got your insurance company to pay for your 2 level ALIF on 6/18/10 ? Everything I have researched says that there are no insurance company's that will pay for that "kind" of fusion. This is what I am wondering. I haven't tried to get this particular fusion approved yet, but from what I have researched on the internet, it doesn't look likely.

I am amazed. I do not have BCBS. I have always thought them to be a BETTER insurance company than UHC! But maybe they are all just the same!

Susanna

[Greg]

Greg,
Am I to understand that you got your insurance company to pay for your 2 level ALIF on 6/18/10 ? Everything I have researched says that there are no insurance company's that will pay for that "kind" of fusion. This is what I am wondering. I haven't tried to get this particular fusion approved yet, but from what I have researched on the internet, it doesn't look likely.

I am amazed. I do not have BCBS. I have always thought them to be a BETTER insurance company than UHC! But maybe they are all just the same!

Susanna

My 2 level ALIF was approved and paid for by the insurance. Getting a fusion done is pretty standard care and usually is not an issue when getting approval from insurance companies (and usually doesnt matter which ins company). Its like breaking your arm and needing a cast.....thats just what you do and is accepted as the standard. Well for fusion, DDD, herniated discs, spondyloethisis, scoliosis, instability of the spine. The fact that gwin and I were denied our fusions by BCBS due to "instability of the spine" is a complete croc of $H1T and never should have happened. I feel as we are the once in a blue moon cases where somebody goofs up and denies us and then the ins company doesnt want to be proven wrong even though they are so they stand behind their decision. I believe mine was denied because I had already met my out-of-pocket cap and the ins would have had to pay 100% and if they could have just denied me for a couple months then my limits would reset...didnt know this at the time. It wasnt until 6 months later that I found a clinical trial for a fusion that would pay for the surgery (very hard to do I might add) and when they checked with insurance is was an easy day, 15 minute phone call for approval. I dont know where you are reading that insurance companies wont pay for fusion but it is pretty much the complete opposite (depending on what your policy says and what your conditions are and what treatments you have tried.

Feel free to PM me if you want to know more or want to talk about it. Take care and best of luck to you. And BTW....2 months post op and I have never felt so good before (at least in my back...SI joints are a whole different story)

[Susanna]

My 2 level ALIF was approved and paid for by the insurance. Getting a fusion done is pretty standard care and usually is not an issue when getting approval from insurance companies (and usually doesnt matter which ins company). Its like breaking your arm and needing a cast.....thats just what you do and is accepted as the standard. Well for fusion, DDD, herniated discs, spondyloethisis, scoliosis, instability of the spine.

Greg,
My insurance, and others that I have researched on the internet say that they cover fusions but not ALIF.

Susanna