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Old 06-20-2014, 04:45 PM   #1
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Default Lady Di and Her Medical Insurance

Hi all,

Buford and other hooligans have send nice messages to Lady Di regarding what was, her upcoming back surgery and I attempted to PM what was going on. There must be a word limit as my PM replies were amputated half way through what I had typed after I sent them, but we do thank you all for for your good wishes.

Unfortunately we have to put our adventure plans on hold. Diana needs a spinal fusion operation as her spine is deteriorating due to osteoporosis and spinal stenosis which she inherited from both her grandmas.

She was set for surgery this early this month, but UCSF advised that our insurance company had denied coverage for the operation and they cancelled the surgery. UCSF originally said they would be doing the appeal but then they advised they could not do the appeal.

We found out that the UCSF was not able to appeal the decision by the insurance company as they no longer are doing insurance appeals because they don’t have the resources or time. The private insurance companies are routinely denying spinal fusion operations and doctors and hospitals do not have the resources to challenge those decisions. Her local pain physician told us that the Affordable Care Act has given the insurance companies new thresholds for many surgeries as well as medications. That physician also said that insurance coverage for many medications are now also being denied by the private insurance carriers. So many hoops and hurdles are needed in order to qualify for this spinal fusion operation. So bottom line is that some bean counter, medical claim reviewer is overruling what is recommended by a world class orthopedic surgeon at UCSF. Diana does not have any other options but surgery and ALL conservative treatments as well as spinal injections haven’t worked and her overall condition will continue to deteriorate. We are PISSED! to say the least.

What’s interesting is that I spent about an hour on the phone with the insurance claim handler who said that last year they were not denying this types of claim. At least he was honest as a low level employee.

So it is up to us to do the appeal which is going to be a headache. Diana is in significant pain daily and we may end up having to hire an attorney if we can’t proceed.

Long and short of it……. no trips for a while, until we get this resolved for Diana.

Here is the insurance company's exclusionary language and the basis of their denial in their letter to her……

Lumbar spinal fusion surgical procedures are considered not medically necessary if the sole indication is any one or more of the following:

1.Disc herniation,
2.Degenerative disc disease (DDD),
3.Initial discectomy/laminectomy for neural structure decompression, Facet syndrome.


So that's the news for now...........
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Old 06-20-2014, 04:56 PM   #2
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Think I have #3 howie, I was denied a mri last month. Think I'll just go to er every time it flares up. Guess now that dot gov is in the mix, a doctor's opinion doesnt matter anymore. Insurance

Very sorry lady Di has to suffer any longer than needed.
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Old 06-20-2014, 05:10 PM   #3
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I'm really sorry to hear this again Howie. Apparently when you "spread the money" out to cover the uncovered there is no money left for procedures for those that have paid for coverage for years and now get crapped upon.

Truly sucks!
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Old 06-20-2014, 05:15 PM   #4
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Sending well wishes and good thoughts
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Old 06-20-2014, 05:19 PM   #5
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My denial letter basically stated not enough medical history on file to warrant procedure
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Old 06-20-2014, 06:43 PM   #6
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Damn Howie! Give Diana our prayers. We thought after talking with you late last month, that the wheels would be in motion by now. So sorry. Keep on plugging away, Somebody will listen.
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Old 06-21-2014, 12:56 AM   #7
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Oh my! I sure hope everything works out for the best.
When my brother needed a quad bypass with no insurance his Dr. Coached him on which hospital ER to go to and exactly what to say to get the ball rolling for surgery. It all worked out and he got his surgery but had to game the system to do it.
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Old 06-22-2014, 04:06 PM   #8
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Sorry to hear of your trouble's, hope you can get it resolved quickly and Di id feeling better soon!!
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Old 06-22-2014, 05:05 PM   #9
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Sorry to hear, I hope it all works out and Steph and i's thoughts and prayers will be with you both
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Old 06-23-2014, 04:52 PM   #10
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thinking of you during this painful time.
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