Anyone had success fighting an insurance denial for back surgery?

I called the Medicare rep at my plan directly and discussed it. She was very helpful (and probably as frustrated as we were by the denial.) The insurers are required to provide "plain language" instructions for appeal, and have quite short windows in which to respond.

Thank you. I have yet to see the actual denial letter,but as soon as it comes in I will file an appeal.
Thank you again for the information.

We were told to decline Medicare advantage and bought supplemental part G I think it is. It is with AARP/United Healthcare which is excellent.

From what I have seen other people experience if at all possible I would never leave my traditional Medicare / United Health Plan. I have seen people lose their life savings because they were somewhere not in network, surgeon wasn’t in network., advantage just didn’t cover . Hospitals also have problems with some Advantage plans, they say they will pay one amount then don’t. They say you need a prior authorization then take forever to get it for you. I honestly feel they definitely don’t have the patients best interest at heart. ❤️

1. Ask for the entire claims /appeals record. My understanding, as the patient you are entitled to all the correspondence.
2. Request/demand the NPI, name and credentials of the "decision-maker" at each stage.
The NPI is a unique identification number for covered health care providers.
https://www.cms.gov/regulations-and-guidance/administrative-simplification/nationalprovidentstand#:~:text=The%20National%20Provider%20Identifier%20(NPI,for%20covered%20health%20care%20providers
Often they have a standard "script" to deny claims, executed by non medical providers.
On appeal it is probably looked at by someone with a medical profession. It should ho to a neurosurgeon, preferably a board certified neurosurgeon, however insurance companies are notorious for not hiring qualified board certified specialists. Sabmves them money but could be a general medicine doc retired for 20 years filling out the denial.
I follow Kaiser Family Foundation news on the insurance issues, denials (I'm a geek that way)
Here's one apparently useful website to look at for further information
https://www.patientadvocate.org/explore-our-resources/insurance-denials-appeals/where-to-start-if-insurance-has-denied-your-service-and-will-not-pay/#:~:text=Reasons%20your%20insurance%20may%20not,requested%20under%20your%20health%20plan

Thank you for the information. I do plan to appeal the denial. My neurosurgeon is going to file an appeal also.
I was informed if I switched to regular medicare next year that I shouldn't have a problem with a denial. Anyone else on standard medicare that has encountered a denial for lumbar back surgery? sugery?

I think you are correct. The advantage plans work on doctor visits and prescriptions. If you need surgery they just deny it. They know most people will just accept a denial and not fight it.
Not me. I'm prepared to go the whole nine yards.
Thank you for your response. Next year, I'm going with standard medicare and never use an advantage program again.

here's what I learned a long time ago:
there is a protocol leading up to surgeries.
You think the doctor would submit it and that it is kept on file.
It is not. So I used to have denials because the "HISTORY" is not forwarded to the insurance company (whomever it is doesn't matter). So you must learn what the insurance company requires for approval and make sure that it is there at your current submitting doctor to be forwarded. I keep my own records. this is necessary.
If it is a pain in the butt, you can immediately file for appeal. I took my insurance company to court to get them to approve REPAYMENT. The judge awarded it.
If you know what the rules are, and follow them, it will work out in the end.
They are counting on you not fighting.

Thank you for the reply. I intend to fight this. You are right, you cannot count on anyone to fight the insurance company but yourself.
May I ask if you did this on your own or did you have counsel? My neurosurgeon said he gave the insurance company three years worth of documentation.
Thank you again.

Crazy hearing about your denial for lumbar surgery with your advantage plan. I have a Blue Cross/Blue Shield advantage medicare plan and have had two lumbar fusion surgeries,one cervical fusion and a carpal tunnel surgery all in the last two years with no hesitation at all by my insurance company. The longer you wait the more damage being done to the nerves involved. Sorry to hear this,best of luck.