Fractured Sacral and osteoporosis why wont insurance let me have surge

dcjac1957,
I sorry you are experiencing so much pain with the non-healing sacrum along with with the insurer. Some offices are more adept at handling these denials foisted upon those less able to defend themselves.
AI was actually pretty helpful
https://www.google.com/search
it is mostly a problem your doctor has to manage. But many times when challenged the person hired by the insurance company (usually not a doctor) will yield. Meanwhile you suffer needless stress and delay of service.
The denial should include information about why or what they expect you to accomplish first. They like you to use conservative (cheaper) measures first.
Are you on osteoporosis medications.
I hope loriesco responds.

I can corroborate gently’s comment on how doctors vary in their skill at navigating prior authorization. My first osteoporosis specialist, a rheumatologist, required weeks to obtain approval for Tymlos. When I’d been on it for three months, Cigna revoked my PA and she didn’t know what to do. They wanted me to go on teriparatide even though I’d be approved for two years of Tymlos. I had to lead the approval process, telling them what the insurance company required, right down to the dose to request. They fumbled the request and kept submitting the incorrect dosage. It took two months and many calls to Cigna and the doctor to get it sorted.

Contrast this to my experience with the endocrinologist I began seeing shortly after. She obtained approval to start Evenity within one week.

There is an appeal process for refusals. 80% are overturned on appeal. The doctor often has to submit additional paperwork or do a peer review first. It’s time consuming and annoying. My husband just went through this with rotator cuff surgery. Cigna sent three denial letters in total. It took several weeks for his surgeon to get approval and he had to call his office repeatedly to remind them to submit the required paperwork. In the end, Cigna approved and he had the surgery. It’s an annoying part of the medical system that we patients have to endure.

Make sure you call your doctor’s office to ensure they follow up. Learn what the appeal process is and get on your doctor to follow up. You shouldn’t have to do this but it’s your health at stake. I hope you can get this over the finish line. I know it’s hard when you are in pain every day. Hang in there.

@oopsiedaisy thanks I was on bonvity but the side effects were killing me,literally. So now I'm going to do the once a year Reclast infusion. But the insurance wants me to do pain injections at least 2 and see the results. But my surgeon said those won't do anything and surgery is the only way to fix. Thanks for the input.

@dcjac1957 Insurance will always drag things out before approving surgery. My husband had to do 12 sessions of physiotherapy before they’d approve an MRI for his torn rotator cuff even though the surgeon diagnosed it as torn on a physical exam. It’s so frustrating that they won’t listen to the surgeon who is the expert.

I hope you can eventually get the surgery approved.

What a nightmare and I wish you success and that your doctor will put forth the fight for you. For anyone who is a senior and facing a choice to make with Medicare: original v Advantage plan. This is is why I pay extra for original Medicare .. Fewer things need prior approval. Most things don’t although this could change with the current administration

Have you appealed to your insurance company? I needed a specific medical procedure and my insurance company denied it. I appealed. They denied it again. So then I appealed it to my state's independent review organization. Every state has one and it's called IRO. I finally won my appeal and got my procedure.

@daisylou Medicare Advantage is exactly the opposite of being an advantage! I think it's a scam myself.

@daisylou I too just switched this year from my Medicare Advantage Plan to original Medicare, along with medgap plan G, a drug plan and a dental plan. It is costly, but I’m willing to give up other things to get original Medicare.

@sandy0257 Good move, Sandy. Advantage plans are cash cows for private insurance companies. Why invite them to restrict who our providers are, and to deny treatments that our doctors order. It’s worth it to be able to go to any doctor who takes Medicare and things get covered without a fight.

@gently There were 2 codes the insurance would not accept and so denied, my wonderful dr./ surgeon said screw them and did my surgery yesterday. Successfully and free of charge to myself. Some doctors out there still do the right thing. Thanks for your reply