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Anyone had success fighting an insurance denial for back surgery?

Spine Health | Last Active: Sep 4 12:13pm | Replies (55)
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@dlydailyhope

@koneil
Which insurance company do you have your Advantage plan through? What levels of your lumbar spine need decompression/fusion? What are your symptoms and treatments thus far?

I had ACDF surgery C5-C6 January 2022 and decompression/fusion with hardware on L3-L5 3 weeks ago (August 2, 2024). I am 55 and on Aetna COBRA after being laid off last year. Aetna made my orthopedic spine specialist jump through hoops to approve the surgery he recommended to address my severe congenital central spinal stenosis and neurogenic claudication. They delay on purpose to delay payments it seems. Aetna was denying at first saying I needed physical therapy but my journey of pain has been 8-12 years. I tried everything, including delaying surgery by getting multiple spinal injections but they stopped helping. Once your discs are bulging significantly and compressing spinal cord, nerve roots/nerves plus having osteoarthritis, PT is very limited in helping. When I had issues with my neck, I was sent for PT as another delay tactic when my spinal cord was being injured due to compression and injury (should have been recommended for surgery sooner but it was missed/overlooked by several doctors and now I have some residual permanent damage to my spinal cord causing weakness/numbness in arms/hands.

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Replies to "@koneil Which insurance company do you have your Advantage plan through? What levels of your lumbar..."
koneil | @koneil | Aug 26 12:14pm

Thanks for the comment. I am not as well versed as you are on the exact diagnosis for my lumbar and cervical spine.
All the tell me is I have S1 and L2 self-fused and I need to have 3 other discs fused as well. They also mention spinal stenosis, and a severely curved spine.
I'll have to get a more comprehensive list from my neurosurgeon.
Thanks again.

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thenazareneshul | @thenazareneshul | Aug 27 11:35am

In my experience, PT is the knee-jerk first thing insurance companies want to see tried. I just had an epidural steroid (in prep for 6 nerve blocks later to L spine) to L5, but the guy (a new-to-me pain management anesthesiologist) was straight up that he'd have to say I was at least doing PT excercises at home, first. Well, since we were then right in the middle of moving from one apartment to another, I said yes. It's a ton of exercising to move, even with movers and my daughter helping me. I had to sit on floor and stretch stuff out a lot, for example.

So, his request cleared. But he also ordered an MRI that showed lots of things wrong with that spine, I'm sure that was part of the approval.

This has happened a lot in the past, when I was working my way up to the MRI's finally showing things wrong with my spine. I'd ask for some help with the pain (like surgery or treatments) and I'd get turned down because I was back then refusing to do PT. Only no one explained it to me, that it was because of that my ins. (no matter what company) would turn it down if I wasn't doing PT or hadn't recently. It's partly because I have fibromyalgia also, and I have exercise intolerance. Something the average Physical Therapist can't deal with. When they say to me "Well! If you don't want to!" And I, would say Okay. Thanks. I only got the fibro official diagnosis this year. I've had it since 1990, along with other stuff, and multiple injuries. In fact, the worst injuries came via a Chiropractic adjustment I'd paid for myself.

Ask your doctor, or even just call his nurse maybe, if you need to qualify with like active PT, to get your ins to approve. Or what it is they require in order to approve what you want? It's a legit question, they need to answer it.

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