Anyone had success fighting an insurance denial for back surgery?

I also wanted to say - you need to know on what basis was the denial! Ask for a copy of the paperwork. Also, find out how your Patient advocate is and asked them to represent you. You can also inform them that you’ll take them to arbitration.

that doesn't make sense to me. You don't have surgery because of an MRI. You have surgery because the Orthopedic Surgeon recommends surgery. They use CPT diagnostic codes to order surgery. That needs to jive with not only an MRI but an Orthopedic X-ray and the work the surgeon wants to do. "Instability" - is meaningless. Your Orthopedic Surgeon READS the MRI themselves. They don't use the "read" of a radiologist. The surgeon will use the read to make quick work and know where to focus. Instability is a judgment call and not a professional assessment.
If your surgeon didn't do their part, that might be the problem. If your back isn't bad enough, and your doctors didn't do the required protocol - deeming it unsuccessful - that also could be a problem!

I'm just repeating what the neurosurgeon stated, and what was written on my denial for surgery. I have been to two different neurosurgeons and both recommended surgery on my lumbar spine.
On the request of the new neurosurgeon, the radiologist did a reread of the mri and concured with my neurosurgeon that I needed surgery on three different levels.
The way medicare advantage works is the doctor sends in his recommendation along with the mri and other test results. If the recommendation falls within their algorithms for surgery, it's approved. Otherwise it's denied. I assure you my back is injured enough for surgery. It's moments like yours that make me wonder why I joined this forum.

Medicare Advantage programs are designed to make money by denying all sorts of things

"The private insurers receive a fixed amount each month for Medicare Advantage plan care. In turn, these companies can charge out-of-pocket costs to policyholders and are able to establish their own rules for service such as the need for referrals or provider networks for both non-urgent care and emergency services."
https://www.investopedia.com/articles/personal-finance/010816/pitfalls-medicare-advantage-plans.asp

Agreed. My Medicare advantage plan is content keeping me on pain management to keep their costs down.

@koneil you are unfortunately experiencing what Medicare Advantage Plans are known for mostly and that is denying care to save money. Advantage Plans are simply HMO’s paid by CMS. They control costs to make money. Your back surgery will require a lot of physical therapy following surgery depending on your outcome. You will cost them a lot of money down the road and they’re counting on you switching. Go to a traditional Medicare plan including Part A, B and C and stay away from Part D. Sorry for your situation. I had fusion surgery in 1988 L4-S1 and still paying the price. Once you’ve had corrective surgery and get a good PT program don’t ever stop doing it. Your back will love you for it.

Thank you. I should get an answer tomorrow on the latest surgery request. At least this new neurosurgeon is on my side. He said he will go to bat for me.
Thank you for the information.

My lumbar back surgery was denied by my insurance company. Anyone out there who has experience in a insurance denial claim for surgery?
That's two different neurosurgeons that recommended surgery on my spine and both were denied. The nurse said that is not unusual. It seems that all insurance companies are denieing surgery. I'm going to fight this one. The Healthcare insurance companies are just looking at their bottom line. They definitely aren't here for the patients!

So sorry that you are having to go thru this accompanied with the pain that got you here in the first place! Could it be that these Docs are not in your network?

Thank you for the reply. No, both neurosurgeons are in network. The nurse at my last visit said that it is very difficult to get any surgeries approved, much less than with a medicare advantage. I'm going to appeal the denial. Anyone have any recommendations?