Anyone had success fighting an insurance denial for back surgery?

Thank you for the comment. The only thing that I an question over is my mri. If it was read as my neurosurgeons did. I should
not have this problem.
Thank you again.

@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.

@koneil your best bet is to fight this on your own. Patients have a lot of sway with their insurance carrier when you get pushy. I’d write them with certified letters and I’d call them as much as possible. The more you nag the better response you’ll get.

Meh,
Sounds somewhat familiar. It is true, different experiences and training will lend to different recommendations and outcomes.
As an exercise physiologist (also with back issues) I would think how I can use what I know to maintain (and maybe build) on what I have. Bones give shape, tendons provide support, but muscles help keep in place. Nerves tell when we need to address a problem. That's just my take and I am not a doctor.
I might also think that AI is a factor here as well. Just keep working on advocacy and what will work for you.

Thanks for your comment. I'm working on this daily. I have a small delay because I fell and shredded what was left of my rotator cuff. Now the neurosurgeon won't touch me until I have a reverse total shoulder replacement. Let's see if blue cross approves the shoulder surgery.

Thank you. I have blue cross on speed dial I've called so much. I didn't think about sending certified letters. Thank you for the advice.

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.

@koneil as a retired nurse and healthcare consultant may I offer some advice. When you find out your true diagnosis use Dr. Google and look for NLM and other sources of medical knowledge for printed data supporting the treatment(s) recommended. Your docs are using protocol to determine the best treatment for you. Use that same data to support your arguments for surgery vs. non-surgical treatment. If I can inquire has BX offered you any alternative treatments other than surgery?

Kaiser Family Foundation newsletter covers the topic of insurance denials from time to time.
You, as the "client" are entitled to the entire file at the insurance company to include who made the denial(s) decision, their credentials (e.g. RN, MD, and so on) AND the National Provider Id number (NPI) of that provider making that call. You can ask for (demand) their specialty and ask if they are board certified as a surgeon --orthopedic or neurosurgeon. Usually first round of denials are by low level non-professional employees from a predetermined script. Appeals go to someone with some medical knowledge but that could be a retired urologist, or GP or internal med doc...or an RN who is not well versed in your spinal conditions nor current on treatment modalities. It's its own kind of corporate maze to work through. One has to be diligent about it all and have a second who can support you through this if possible because pain, pain meds etc can also slow you down while you are stuck doing all your slef-advocacy.

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.