Spinning My Wheels!

So I visit my new spine surgeon in Texas and I learn that I am a good candidate for the new ADR procedure! Hooray, right? Well yes until my insurance company decides that they indeed do not cover it now due to the fact they consider it "investigational" at that time. Now try to get them to explain what this means and the difference between that term and experimental is like trying to pull hen's teeth and my grandma would say!
I spent the next four to five months in constant severe back pain working on legal appeals to get my surgery approved. Even though the device was FDA approved at that time, insurance companies were still reluctant to cover it. This made no sense to me as from a financial standpoint, ADR cost half what the two level lumbar fusion cost. From a physical standpoint, most people were back to work within six to eight weeks as opposed to a three to six month wait for normal function after a fusion. The chance of causing further damage to the spine was a huge concern for me as well!
I researched, sent truckloads of paperwork to the insurance company and spent hours on end calling their representatives and my medical case manager which was a huge joke! What I found out is this. The first appeal is judged worthy or not by the in house medical director at the insurance company. This can be any kind of doctor. In my case it was an OB/GYN. Now how can someone in that field decide if I need this surgery or not? Well they tell me the "next" appeal level will be "independent". Yeah, right! The insurance company decides who does this appeal and "pays" the doctor that does the assessment. In my case this was a orthopedic doctor. His report had several errors and I was furious when I got it. I found out, through an oooops at the insurance company that this doctor was local to me.
I politely got on the phone and called his office to see what his field of expertise was. I figured well if he knew better how to take care of me than the other 8 surgeons I had seen and consulted with, I would give him a whirl. I asked about an appointment for my low back issues and was told he does shoulder surgery! HUH??? I then said well I am confused he did an evaluation on me for my insurance company and I thought he was an "expert" in this area. You are telling me he doesn't even treat spine patients? So, so much for an "independent" evaluation! Personally I cannot believe that anyone who is paid by the insurance company will be particularly sympathetic to my plight as they would like to get further referrals. I also found out later insurance executives get HUGE bonuses for saving the company money by denying procedures such as this.
My third and final appeal was sent with a letter describing all the "travesties" that they had put me through and that I was appalled that someone who had no knowledge of up to date procedures or treatment in this field could evaluate my situation thoroughly. This time after another 30 days, the cut off for them to approve or deny appeals, I was denied again by a neurosurgeon.
By this time I was exhausted both physically and mentally. I contacted the representative at my husband's employer to see if anything else could be done since our policy is self paid by the company. I was told I could appeal to them to get the funds for the surgery even though the insurance had denied it. I had 30 days to do this. I received all the forms to turn in for this on the 31st day so that was a bust!
Chronic pain takes its toll on your physically and mentally to say the least. Fighting with insurance to get medical treatment just adds to the frustration and angst that I had to go through. My life revolved around this issue and it was sad to say the least that I could not live or enjoy my family due to all this!

More tomorrow!

Images courtesy of Pocheco at stockxpert.com