There are no medical professionals on this forum side of the site. Therefore, no one is capable or permitted to provide any type of medical advice.
This includes any analysis, interpretation, or advice based on any diagnostic test

The main site has all the formal medical articles and videos for you to research on.

Are Medical Policies Killing Us/Me?

nutcase007nnutcase007 United StatesPosts: 937
edited 04/05/2016 - 5:07 AM in Back Surgery and Neck Surgery

 I have a neck condition given to me where I had my neck broken because of being rear ended in a car accident.  I have already have two fusions in my neck over the last ten years.  I never recovered from my last fusion.  I have severe pain in my neck, shoulders and upper back.  I addition, I have significant loss of motor function in my one arm.  I have had multiple MRIs, bone scans and x-rays.  All the tests keep coming back with "Can't find any significant problem, nothing to be done".  I've lost my job, cannot work and have been denied LTD disability.  The accident happen many years ago, so the statutes of limitations ran out before I started having neck problems.

My last neck fusion was two years ago.  The surgeon made the comment after surgery that he didn't understand how I still had any motor function left in my arms or legs.  Recovery went well for six months and then turned bad.  At twelve months, things got so bad that I had another round of tests (MRI, bone scan and x-rays) and went on short term disability.  From the bone scan, the broken facet joint at the level that had been fused twelve months earlier was still very inflamed, so a nerve oblation (RFA) was performed.  I was able to get back to work for a few months, but my neck continued to deteriorate.  I could no longer continue work and was fired from my job.  

The last two paragraphs are all background to my up coming question.  Recently, I was back in my surgeon's office showing him my increasing loss of motor function in my arm.  He ordered a Cervical Discogram which was denied by the insurance authorization request, because the insurance companies "determine cervical discograms to be experimental".  That is being fought on appeal for medical necessity.  They will gladly do the cervical discogram, if I pay for it (if I only had the money).  On the internet, I found one of the insurance companies policies published for discograms and they state only to be performed when, I quote "unremitting pain with significant functional impairment of at least twelve months duration".  I asked the insurance company how these policies are determined and they claim they are developed based upon guidelines from the medical professional boards (aka AMA, etc). 

Here is my question, are doctors hands being tied by "guidelines / medical policies"?  This goes beyond what an insurance company determines what they will pay.  To me, it smells like this doctor could have been accused of bad medicine if he had not followed medical guidelines and would have ordered a discogram a year ago.  I am being told that this cervical discogram is the only remaining test that might identify the cause my neck issues.  It is documented that some disc issues are known to NOT show up on MRIs, bone scans and x-rays.  So it smells to me that I have been forced to suffer for an additional twelve months and lose my job because of medical policy!     



  • nutcase007nnutcase007 United StatesPosts: 937
  • nutcase007nnutcase007 United StatesPosts: 937

    Thanks itsautonomic for sharing your experience.  Its good to hear a success story. 

    On the "experimental" part, the insurance company claimed that experimental means in insurance legalese that general excepted medical policy does not approve this procedure except on individual documented medical necessity cases.  I think I'm almost saying the same thing you wrote.

    If you want to make your head spin, Google "cervical discogram experimental" and read some of the posted policies.   

  • advertisement
  • dilauroddilauro ConnecticutPosts: 12,303
    edited 06/19/2019 - 3:18 PM
    Cant say for all cases, but I do know first hand that the doctor's hands are being tied and they are being forced by the insurance companies on what can be done.  Medicare then throws a bigger problem into the barrel making it so more difficult for doctors.

    I would not want to be a doctor today who needed to code and justify a condition or treatment for a patient. It is so difficult,

  • gfishggfish Pittsburgh PAPosts: 239
    My experience would be that my insurance wont let my doctors go in to have a look around with an MRI or Ct scan. Only if truly needed. Any medical procedure would have to show warrant. Not, we could try this and see if it works. Im kind of like you in the same boat. I had a major fusion. Didnt  end up so well.  Actually worse. My Insurance is spending money on me for PT, Pain management doctors and other stuff for over a year now.  But hold back on the real money. I think they look at us like a risk. That we might never get any better so why pour money into someone that will always be like this. 
    Greg fisher
  • nutcase007nnutcase007 United StatesPosts: 937

    In answer to my question that I posted two years ago, yes, medical policies are killing some of us!

    If you google "cervical instability", one of the first URLs should be from Physiopedia.  It is an excellent white paper!  The paper goes on to say there is basically no diagnostic tests for cervical instability.  Per my neurosurgeon, the only shot he had to prove cervical instability was a cervical discogram, which once was an approved medical procedure, but was later rescinded to experimental status.

    Now comes the ugly part:  I was left to rot for two additional years, even though my neurosurgeon "in his gut" thought I had cervical instability for the cause of my issues.  My condition had to get so bad and become what my neurosurgeon calls "gross cervical instability" and now he is per medical protocol and insurance practice allowed to perform an ACDF on me.  I am now scheduled for my third cervical ACDF in two days.  After this fusion, I will be fused from C2 to C7.  Oh, by the way, over the last two years, I've had ten second opinions.  It was only with the 10th second opinion that the "ball got rolling" to change my condition diagnosis to gross cervical instability.  In those 10 second opinions, I had visited multiple "nationally recognized" teaching hospitals.      

    Am I angry?  I need to defer that emotion.  I need to focus to get to surgery, get thru surgery and hopefully have a chance of some improvement of quality of life.  I'll need to revisit my anger at a later time.     

  • advertisement
  • dilauroddilauro ConnecticutPosts: 12,303


    Thank you for deferring your anger to a later time... Concentrate on the main thing, your next surgery

Sign In or Join Us to comment.