Anyone had success fighting an insurance denial for back surgery?

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.

@thenazareneshul
My experience has been my orthopedic doctor recommended certain things and my insurance would deny and then he would need to do peer to peer reviews to justify what was needed to get it approved. My various doctors’ offices would let me know my insurance companies required PT first, depending on the diagnosis/codes submitted to insurance. You can always call the insurance companies yourself with the information and codes from your doctors to ask questions about coverage and requirements. For example, my recent surgery lead initially denied due to not doing PT in the last 6 months but when my surgeon provided MRI/medical notes, it showed how bad my spine was, that I had a history of doing pain injections to delay surgery and now I needed surgery done the injections were no longer working. I had done PT a long time ago and it helped some but it wasn’t going to change the fact I had congenital spinal stenosis, osteoarthritis in my spine and degenerative disc disease.

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.

@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?

@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?