insurance Coverage for procedureappeals option

if insurance medical guidelines indicate they won’t cover artificial disc, has anyone out there had luck with an appeal, or ability to have procedure w/o insurance coverage some other way? 



  • AJGormitAAJGormit Posts: 2,087
    edited 07/23/2019 - 1:08 PM

    hi bethdori

    Welcome to Veritas Health Forum

    maybe your medical team would be able to advise on this as they may have had experience at assisting a patient with an appeal of this nature.

    i have added two links below to help new members with information and these also contain the forum rules.  there is lots of material to research that will give you the power of knowledge.

    welcome to spine health

    all new members should take the system tutorial 

  • Joel1QJJoel1Q Posts: 235
    edited 01/23/2018 - 2:48 AM

    Hi bethdori.  I am pending 3 level ALIF (L3-S1) with interbody cages and possible additional PLIF fusion with rods/screws if the ALIF isn't 100% successful at the time of procedure, which was denied by insurance after the first submittal in November 2017.

    Aj has given me the same advice about letting your experienced medical team advise as to the best path forward with an appeal, as I had insurance deny the first submitted overall procedure due to a technicality in the Radiologist reading of the MRI.  The medical team successfully appealed as I found out today, but now my frustrating insurance company denied a second part of the procedure, the interbody cage graft material type as being "experimental and having no clinical evidence of effectiveness over other standard implants."  My research to confirm this is difficult to find, but I know the graft material is the 'gold standard' of bone graft...why would one want anything less?  I'm waiting for the medical team to advise, but it feels like insurance is being cheap, approving knock off generic Pep Boys parts to fix a car when I really need the best possible GM parts to resolve my cadillac part issue.

    I too wonder if there are other options for payment beyond health care - out of pocket or supplemental or other insurance, but obtaining it for pre-existing conditions is a challenge.  Private medical options are just not affordable for me.  I've heard of people going to pay completely out of pocket for tests in various parts of SoCal where I live but this sounds sketchy and wouldn't think this would be an option for surgery (except to move to Norway and become a legalized citizen :) ).

    I know that when i went planned to do the steroid injections last year following my setback and nerve damage, the MRI to confirm diagnosis to try all things before surgery like injections was originally denied by insurance and I had to wait and go through 6 weeks of painful PT before I could even get MRI approval to confirm the injections would help.  Then secondly, of the three types of planned injections, the second was a type of dual injection at the L3 level due to dual pinched nerves from disc bulges, and was again denied by insurance.  My medical team worked through that - taking time to resolve was frustrating to deal with pain when there was a hopeful treatment...but it ended up that injections marginally helped and here I am waiting for the surgery approval...again, dealing with more pain that should be necessary and having zero quality of life for months, seemingly unnecessarily.  Couldn't be more frustrated with my insurance coverage, PPO which I pay through the nose for and slow progress.

    I pray we both fair better with the appeal process and get to where we want to be like everyone on this site, living a quality of life pain free, or at least much better off pain-wise than we are now.


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